Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist |
NPI | 1487743696 |
---|---|
Provider Name | Mr. Brian Franklin Moore |
First Address | Slidell, LA 70461-5418 |
Second Address | Slidell, LA 70461-5418 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1199311 | (05) | LA |