Basic Information
| Provider Information | |||||||||
| NPI: | 1528263514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | CECILIA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | STOP 9903 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794309903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067437337 | ||||||||
| FaxNumber: | 8067437329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 05/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1004X | DT80334 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
ID Information
| ID | Type | State | Issuer | Description | 13785036 | 05 | NM | MEDICAID | 193439001 | 05 | TX | MEDICAID | 8H8762 | 01 | TX | BC/BS | OTHER |