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General NPI Number Information
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NPI Number | 1194987529
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Entity Type | Individual
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Provider Name | KELVIN MOORE OT
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Gender | Male
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Dates
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Enumeration Date | 06/26/2008
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Last Update Date | 08/25/2022
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Provider Practice Location Address
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Address Line | 711 AVIGNON DR
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City | RIDGELAND
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State | MS
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Zip | 39157-5120
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Country | US
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Telephone | 601-605-6777
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Fax | 601-605-8869
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Provider Business Mailing Address
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Address Line | PO BOX 22
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City | SENATOBIA
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State | MS
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Zip | 38668-0022
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT2229
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License Number State | MS
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