Provider Demographics
NPI:1841679891
Name:COREY A. MOORE UBU SPORTS MENTORING
Entity type:Organization
Organization Name:COREY A. MOORE UBU SPORTS MENTORING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECT SUPERVISON
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MBA
Authorized Official - Phone:941-587-4953
Mailing Address - Street 1:5135 CAMINO AL NORTE AVE., SUITE 100
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-8104
Mailing Address - Country:US
Mailing Address - Phone:941-587-4953
Mailing Address - Fax:702-853-7001
Practice Address - Street 1:5135 CAMINO AL NORTE AVE., SUITE 100
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-8104
Practice Address - Country:US
Practice Address - Phone:941-587-4953
Practice Address - Fax:702-853-7001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UBU SPORTS MENTORING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-22
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20151051263251S00000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty
Yes251S00000XAgenciesCommunity/Behavioral Health