Provider Demographics
NPI:1083825277
Name:MOORE, KYLE ANDRE (PTA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ANDRE
Last Name:MOORE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 21ST ST
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-4558
Mailing Address - Country:US
Mailing Address - Phone:973-373-1819
Mailing Address - Fax:973-373-1819
Practice Address - Street 1:600 S LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5419
Practice Address - Country:US
Practice Address - Phone:973-740-9001
Practice Address - Fax:973-740-9007
Is Sole Proprietor?:No
Enumeration Date:2007-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00186200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant