Provider Demographics
NPI:1831391408
Name:MOORE, RODNEY SHANE
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:SHANE
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 938
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:VA
Mailing Address - Zip Code:24243-9740
Mailing Address - Country:US
Mailing Address - Phone:276-523-2884
Mailing Address - Fax:276-523-4902
Practice Address - Street 1:RR 1 BOX 938
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:VA
Practice Address - Zip Code:24243-9740
Practice Address - Country:US
Practice Address - Phone:276-523-2884
Practice Address - Fax:276-523-4902
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705 113696171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications