Healthcare Provider Details

I. General information

NPI: 1588607147
Provider Name (Legal Business Name): KENNETH L MOY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18321 CLARK ST
TARZANA CA
91356-3501
US

IV. Provider business mailing address

PO BOX 660640
ARCADIA CA
91066-0640
US

V. Phone/Fax

Practice location:
  • Phone: 818-708-5170
  • Fax: 818-705-2595
Mailing address:
  • Phone: 626-447-0296
  • Fax: 626-447-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG32374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: