Provider Demographics
NPI:1891841045
Name:MOORE, KIMBERLY REIKO (MPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:REIKO
Last Name:MOORE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6958 GRANDWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-2238
Mailing Address - Country:US
Mailing Address - Phone:408-391-7123
Mailing Address - Fax:
Practice Address - Street 1:260 INTERNATIONAL CIR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1130
Practice Address - Country:US
Practice Address - Phone:408-391-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-27
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist