MEDICARE: MR. KEVIN MOUA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	347E00000X	Transportation Broker		WI

General Provider Information

NPI Number	:	1750975744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN MOUA

Provider Business Mailing Address
First Line	:	8820 W MILL RD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-1840
Country	:	US
Telephone Number	:	414-797-0616
Fax Number	:	414-635-3169

Provider Business Practice Location Address
First Line	:	8820 W MILL RD
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-1840
Country	:	US
Telephone Number	:	414-797-0616
Fax Number	:	414-635-3169

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2021
Last Update Date	:	02/22/2021

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