Basic Information
| Provider Information | |||||||||
| NPI: | 1629228309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4702 W COMMERCIAL DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721167068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018125545 | ||||||||
| FaxNumber: | 5018125546 | ||||||||
| Practice Location | |||||||||
| Address1: | 4702 W COMMERCIAL DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721167068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018125545 | ||||||||
| FaxNumber: | 5018125546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 09/30/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.