Provider Demographics
NPI:1770151110
Name:MOORE, KIM REAVIS
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:REAVIS
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-7784
Mailing Address - Country:US
Mailing Address - Phone:336-399-9764
Mailing Address - Fax:
Practice Address - Street 1:3000 BETHESDA PL STE 701
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3329
Practice Address - Country:US
Practice Address - Phone:336-399-9764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC53225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist