Basic Information
| Provider Information | |||||||||
| NPI: | 1558503847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 339 | ||||||||
| Address2: | |||||||||
| City: | ZUNI | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873270339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057824710 | ||||||||
| FaxNumber: | 5057825880 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 D AVENUE | ||||||||
| Address2: | |||||||||
| City: | ZUNI | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057824710 | ||||||||
| FaxNumber: | 5057825880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2009 | ||||||||
| LastUpdateDate: | 04/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0110951 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.