Provider Demographics
NPI:1255456380
Name:MOORE, MARGARETTA HINES (ADMINISTRATOR)
Entity type:Individual
Prefix:MRS
First Name:MARGARETTA
Middle Name:HINES
Last Name:MOORE
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 MANCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-5536
Mailing Address - Country:US
Mailing Address - Phone:336-727-1308
Mailing Address - Fax:336-723-8142
Practice Address - Street 1:2224 MANCHESTER ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-5536
Practice Address - Country:US
Practice Address - Phone:336-727-1308
Practice Address - Fax:336-723-8142
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL 034024311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801419Medicaid