Provider Demographics
NPI:1730823238
Name:MOORE, KEVIN (LMT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH WILDWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08260-3023
Mailing Address - Country:US
Mailing Address - Phone:917-607-7016
Mailing Address - Fax:
Practice Address - Street 1:506 OHIO AVE
Practice Address - Street 2:
Practice Address - City:NORTH WILDWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08260-3023
Practice Address - Country:US
Practice Address - Phone:917-607-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010975225700000X
NY010965225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist