Provider Demographics
NPI:1801250667
Name:MOORE MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:MOORE MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DNP/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:PARK
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:731-617-1883
Mailing Address - Street 1:600 MAIN ST
Mailing Address - Street 2:P. O. BOX 41
Mailing Address - City:FRIENDSHIP
Mailing Address - State:TN
Mailing Address - Zip Code:38034-1999
Mailing Address - Country:US
Mailing Address - Phone:731-677-3400
Mailing Address - Fax:731-677-3402
Practice Address - Street 1:600 MAIN ST
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:TN
Practice Address - Zip Code:38034-1999
Practice Address - Country:US
Practice Address - Phone:731-677-3400
Practice Address - Fax:731-677-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16606363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty