Healthcare Provider Details

I. General information

NPI: 1639572068
Provider Name (Legal Business Name): KENNETH MOODY SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2014
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043 ABERDEEN RD
HAMPTON VA
23666-4803
US

IV. Provider business mailing address

1043 ABERDEEN RD
HAMPTON VA
23666-4803
US

V. Phone/Fax

Practice location:
  • Phone: 757-597-1453
  • Fax: 757-838-7663
Mailing address:
  • Phone: 757-597-1453
  • Fax: 757-838-7663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number2599
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: