Provider Demographics
NPI:1477987139
Name:MOORE, KYLE PATRICK (MS, ATC, LAT, CSCS)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:PATRICK
Last Name:MOORE
Suffix:
Gender:M
Credentials:MS, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:HUNLOCK CREEK
Mailing Address - State:PA
Mailing Address - Zip Code:18621-4000
Mailing Address - Country:US
Mailing Address - Phone:610-223-3755
Mailing Address - Fax:
Practice Address - Street 1:40 COAL ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-5236
Practice Address - Country:US
Practice Address - Phone:570-270-6432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0052612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer