Basic Information
| Provider Information | |||||||||
| NPI: | 1154785616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | VON | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S CHIPETA WAY | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817951 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 S CHIPETA WAY | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817951 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2016 | ||||||||
| LastUpdateDate: | 06/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 62587 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 2084A0401X | 11273463-1204 | UT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 207Q00000X | 11273463-1204 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.