Healthcare Provider Details

I. General information

NPI: 1073006821
Provider Name (Legal Business Name): KEVIN CHARLES MORAN MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KEVIN CHARLES MARTIN MS

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-3575 KAMOLEHONUA ST UNIT 806
EWA BEACH HI
96706-6882
US

IV. Provider business mailing address

91-3575 KAMOLEHONUA ST UNIT 806
EWA BEACH HI
96706-6882
US

V. Phone/Fax

Practice location:
  • Phone: 419-680-0551
  • Fax:
Mailing address:
  • Phone: 419-680-0551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: