Provider Demographics
NPI:1285392191
Name:MOORE, JAMES BRODERICK
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:BRODERICK
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 1:150 JOHNSTAN ST
Mailing Address - Street 2:
Mailing Address - City:OWINGSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40360-2029
Mailing Address - Country:US
Mailing Address - Phone:606-336-1756
Mailing Address - Fax:
Practice Address - Street 1:209 EVANS AVE
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9700
Practice Address - Country:US
Practice Address - Phone:859-498-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT19402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer