Provider Demographics
NPI:1134575400
Name:MORAN, KYLE SCOTT
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:SCOTT
Last Name:MORAN
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 1:2167 RIDGECREST RD SE
Mailing Address - Street 2:APT. #4
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4382
Mailing Address - Country:US
Mailing Address - Phone:810-305-2955
Mailing Address - Fax:
Practice Address - Street 1:2167 RIDGECREST RD SE
Practice Address - Street 2:APT. #4
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4382
Practice Address - Country:US
Practice Address - Phone:810-305-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner