Healthcare Provider Details

I. General information

NPI: 1659770006
Provider Name (Legal Business Name): MOIRA KATHRINE KILEY LATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 CABOT ST STE 6
BEVERLY MA
01915-4526
US

IV. Provider business mailing address

27 THORNDIKE ST UNIT 1
BEVERLY MA
01915-5854
US

V. Phone/Fax

Practice location:
  • Phone: 978-927-8945
  • Fax:
Mailing address:
  • Phone: 978-767-6606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number547
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: