Provider Demographics
NPI:1881305613
Name:MOORE, ANTUAN JAMAINE
Entity type:Individual
Prefix:
First Name:ANTUAN
Middle Name:JAMAINE
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 1:11201 SHAKER BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-3869
Mailing Address - Country:US
Mailing Address - Phone:855-930-1771
Mailing Address - Fax:855-544-1518
Practice Address - Street 1:11201 SHAKER BLVD STE 205
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3869
Practice Address - Country:US
Practice Address - Phone:855-930-1771
Practice Address - Fax:855-544-1518
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH873159421OtherTRANSPORT