Provider Demographics
NPI:1679300966
Name:MOORE, KOBI
Entity type:Individual
Prefix:
First Name:KOBI
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1912 GREEN MOUNTAIN DR APT 195
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-4041
Mailing Address - Country:US
Mailing Address - Phone:281-979-3097
Mailing Address - Fax:
Practice Address - Street 1:1912 GREEN MOUNTAIN DR APT 195
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-4041
Practice Address - Country:US
Practice Address - Phone:281-979-3097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer