Provider Demographics
NPI:1184250912
Name:MOORE, KASEEM S (AMBULETTE DRIVER)
Entity type:Individual
Prefix:MR
First Name:KASEEM
Middle Name:S
Last Name:MOORE
Suffix:
Gender:M
Credentials:AMBULETTE DRIVER
Other - Prefix:MR
Other - First Name:KASEEM
Other - Middle Name:A
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:25 POND HILL LN
Mailing Address - Street 2:
Mailing Address - City:WALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:12586-2264
Mailing Address - Country:US
Mailing Address - Phone:845-275-2632
Mailing Address - Fax:845-713-4656
Practice Address - Street 1:25 POND HILL LN
Practice Address - Street 2:
Practice Address - City:WALDEN
Practice Address - State:NY
Practice Address - Zip Code:12586-2264
Practice Address - Country:US
Practice Address - Phone:845-275-2632
Practice Address - Fax:845-713-4656
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY806599263172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No172A00000XOther Service ProvidersDriver