=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033527627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE JOHN MOYER MS, LAT, ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2014
-----------------------------------------------------
Last Update Date | 06/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2601 GRANDVIEW BLVD
-----------------------------------------------------
City | WEST LAWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19609-1300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-678-0180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 353 S WYOMISSING AVE
-----------------------------------------------------
City | SHILLINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19607-2537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-797-3519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | RT005963
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------