Healthcare Provider Details

I. General information

NPI: 1619278082
Provider Name (Legal Business Name): KALA MARIE MOORE LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

852 W KATHLEEN AVE
COEUR D ALENE ID
83815-9405
US

IV. Provider business mailing address

15404 E SPRINGFIELD AVE SUITE 100
SPOKANE VALLEY WA
99037
US

V. Phone/Fax

Practice location:
  • Phone: 208-666-6665
  • Fax:
Mailing address:
  • Phone: 509-892-9800
  • Fax: 509-892-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA60183873
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: