Provider Demographics
NPI:1619040037
Name:MOORE, KEVIN R
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10528 NW 57TH CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-2810
Mailing Address - Country:US
Mailing Address - Phone:954-825-8302
Mailing Address - Fax:954-345-3789
Practice Address - Street 1:10528 NW 57TH CT
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076-2810
Practice Address - Country:US
Practice Address - Phone:954-825-8302
Practice Address - Fax:954-345-3789
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator