Provider Demographics
NPI:1821536756
Name:MOON, KIARA (DPT)
Entity Type:Individual
Prefix:
First Name:KIARA
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KIARA
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:15531 S NORMANDIE AVE
Mailing Address - Street 2:APT B
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4040
Mailing Address - Country:US
Mailing Address - Phone:253-720-3615
Mailing Address - Fax:
Practice Address - Street 1:7872 WALKER ST
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1796
Practice Address - Country:US
Practice Address - Phone:714-670-7347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-11
Last Update Date:2017-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist