Healthcare Provider Details

I. General information

NPI: 1386831691
Provider Name (Legal Business Name): MR. KEVIN A. MORAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5110 PARK RD SUITE 1C
CHARLOTTE NC
28209-3699
US

IV. Provider business mailing address

5110 PARK RD SUITE 1C
CHARLOTTE NC
28209-3699
US

V. Phone/Fax

Practice location:
  • Phone: 704-405-0155
  • Fax: 704-523-5701
Mailing address:
  • Phone: 704-405-0155
  • Fax: 704-523-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1224
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: