MEDICARE: MR. KENNETH WAYNE MOFFETT SR. REGISTERED CERTIFIED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1144050766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH WAYNE MOFFETT SR. REGISTERED CERTIFIED

Provider Business Mailing Address
First Line	:	1315 N COOPER ST #126
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-5564
Country	:	US
Telephone Number	:	214-462-5387
Fax Number	:

Provider Business Practice Location Address
First Line	:	1315 N COOPER ST #126
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-5564
Country	:	US
Telephone Number	:	214-462-5387
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2024
Last Update Date	:	08/07/2024

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