Provider Demographics
NPI:1699738393
Name:MOSELEY, KEVIN W (MPT ATC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:W
Last Name:MOSELEY
Suffix:
Gender:M
Credentials:MPT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COCA BAY PT
Mailing Address - Street 2:1
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913
Mailing Address - Country:US
Mailing Address - Phone:501-760-7440
Mailing Address - Fax:501-760-7442
Practice Address - Street 1:1510 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913
Practice Address - Country:US
Practice Address - Phone:501-760-7440
Practice Address - Fax:501-760-7442
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2319225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W137OtherBCBS
AR5W137OtherBCBS