Healthcare Provider Details

I. General information

NPI: 1699630160
Provider Name (Legal Business Name): MISS KENIAH MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6041 BRISTOL PKWY STE 100
CULVER CITY CA
90230-6601
US

IV. Provider business mailing address

314 S ALEXANDRIA AVE APT 609
LOS ANGELES CA
90020-2621
US

V. Phone/Fax

Practice location:
  • Phone: 310-303-1161
  • Fax:
Mailing address:
  • Phone: 661-221-0568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: