Basic Information
Provider Information | |||||||||
NPI: | 1629165097 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | KNOBLE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | BA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1161 N EL DORADO PL STE 103 | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857154607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207487108 | ||||||||
FaxNumber: | 5207481458 | ||||||||
Practice Location | |||||||||
Address1: | 10247 E COVINGTON ST | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857482146 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5202909055 | ||||||||
FaxNumber: | 5207481458 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2006 | ||||||||
LastUpdateDate: | 05/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 385HR2055X | 4698 | AZ | N |   | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | 253J00000X | 4698 | AZ | Y |   | Agencies | Foster Care Agency |   |
ID Information
ID | Type | State | Issuer | Description | 754871 | 05 | AZ |   | MEDICAID |