Provider Demographics
NPI:1669409967
Name:MOORE, KENNETH EARL (ATC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:EARL
Last Name:MOORE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-4023
Mailing Address - Country:US
Mailing Address - Phone:580-208-2804
Mailing Address - Fax:
Practice Address - Street 1:901 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7802
Practice Address - Country:US
Practice Address - Phone:580-212-9785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAT-662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer