Provider Demographics
NPI:1750839684
Name:MOORE, DYLAN TYLER (ATC)
Entity Type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:TYLER
Last Name:MOORE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:CONCORDIA
Mailing Address - State:KS
Mailing Address - Zip Code:66901-3321
Mailing Address - Country:US
Mailing Address - Phone:785-614-2637
Mailing Address - Fax:
Practice Address - Street 1:600 PARK ST # 1
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-4009
Practice Address - Country:US
Practice Address - Phone:785-628-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-011322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer