Provider Demographics
NPI:1467337121
Name:MOORE, KAVAREE LESLIE
Entity type:Individual
Prefix:
First Name:KAVAREE
Middle Name:LESLIE
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 1:1670 CHIANTI WAY
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561-2232
Mailing Address - Country:US
Mailing Address - Phone:510-926-8624
Mailing Address - Fax:
Practice Address - Street 1:1020 SERPENTINE LN SUITE 102
Practice Address - Street 2:1670 CHIANTI WAY
Practice Address - City:OAKLEY
Practice Address - State:CA
Practice Address - Zip Code:94561
Practice Address - Country:US
Practice Address - Phone:408-457-4182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist