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General NPI Number Information
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NPI Number | 1376515361
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Entity Type | Individual
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Provider Name | KENNETH R MOULTRIE OD
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Gender | Male
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Dates
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Enumeration Date | 02/03/2006
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Last Update Date | 02/02/2017
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Provider Practice Location Address
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Address Line | 600 WASHINGTON ST NW
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City | HUNTSVILLE
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State | AL
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Zip | 35801-4751
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Country | US
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Telephone | 256-533-6838
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Fax | 256-533-1910
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Provider Business Mailing Address
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Address Line | 15933 CLAYTON RD SUITE 201
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City | BALLWIN
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State | MO
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Zip | 63011-2172
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Country | US
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Telephone | 636-200-4393
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Fax | 636-527-0766
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | S536TA063
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License Number State | AL
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