Healthcare Provider Details

I. General information

NPI: 1194987529
Provider Name (Legal Business Name): KELVIN MOORE OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 AVIGNON DR
RIDGELAND MS
39157-5120
US

IV. Provider business mailing address

PO BOX 22
SENATOBIA MS
38668-0022
US

V. Phone/Fax

Practice location:
  • Phone: 601-605-6777
  • Fax: 601-605-8869
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT2229
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: