Healthcare Provider Details

I. General information

NPI: 1134490766
Provider Name (Legal Business Name): MR. KENNETH MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 ORANGE AVE
SAINT CLOUD FL
34769-3063
US

IV. Provider business mailing address

751 ORANGE AVE
SAINT CLOUD FL
34769-3063
US

V. Phone/Fax

Practice location:
  • Phone: 407-967-7128
  • Fax:
Mailing address:
  • Phone: 407-967-7128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2083
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: