Provider Demographics
NPI:1497401277
Name:MOORE, KEITH (CR, LMT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:CR, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3938 LANTERN DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-2321
Mailing Address - Country:US
Mailing Address - Phone:202-437-2507
Mailing Address - Fax:
Practice Address - Street 1:10410 KENSINGTON PKWY STE 207
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2947
Practice Address - Country:US
Practice Address - Phone:202-437-2507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM04099225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist