Basic Information
| Provider Information | |||||||||
| NPI: | 1932630902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KELLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1029 KAPAHULU AVE STE 502 | ||||||||
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| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968161332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087821861 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1611 PLUMMER ST #112E | ||||||||
| Address2: | |||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914032036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188917711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2017 | ||||||||
| LastUpdateDate: | 01/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | ANTICIPATED 06/2017 | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 152W00000X | OD-838 | HI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.