Provider Demographics
NPI:1902493422
Name:MOORE, ELIZABETH DIANA
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DIANA
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 ATHENA CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2800
Mailing Address - Country:US
Mailing Address - Phone:310-714-4753
Mailing Address - Fax:
Practice Address - Street 1:1006 ATHENA CT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2800
Practice Address - Country:US
Practice Address - Phone:310-714-4753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider