Basic Information
| Provider Information | |||||||||
| NPI: | 1659495877 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANDICE MOORE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OUTPATIENT PSYCHIATRIC SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
| Address2: | |||||||||
| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 W ASHLAND ST | ||||||||
| Address2: | |||||||||
| City: | NEVADA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647721712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4174485800 | ||||||||
| FaxNumber: | 4174485800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | CANDICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4174485800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.