Provider Demographics
NPI:1841062080
Name:MOORE, LILLIAN R
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20741 PATTERSON PKWY
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7010
Mailing Address - Country:US
Mailing Address - Phone:216-570-2611
Mailing Address - Fax:216-763-0404
Practice Address - Street 1:20741 PATTERSON PKWY
Practice Address - Street 2:
Practice Address - City:HIGHLAND HILLS
Practice Address - State:OH
Practice Address - Zip Code:44122-7010
Practice Address - Country:US
Practice Address - Phone:216-570-2611
Practice Address - Fax:216-763-0404
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRF524481172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver