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Individual

MR. OTHA MOORE

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man

Contact information

Practice address
18430 WESTHAMPTON, SOUTHFIELD, MI 48075
(313) 844-1496
Mailing address
18430 WESTHAMPTON AVE, SOUTHFIELD, MI 48075-4116
(313) 844-1496

Taxonomy

Speciality
Code
Description
License number
State
302F00000X
Exclusive Provider Organization
Primary
7153185
MI

Other

Enumeration date
09/22/2015
Last updated
09/22/2015
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