Healthcare Provider Details

I. General information

NPI: 1952471625
Provider Name (Legal Business Name): MR. JORDAN HARRISON MOSS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 INVERNESS CORS
BIRMINGHAM AL
35242-3785
US

IV. Provider business mailing address

5025 GRAND ROCK RD
BIRMINGHAM AL
35223-1647
US

V. Phone/Fax

Practice location:
  • Phone: 205-991-3338
  • Fax:
Mailing address:
  • Phone: 205-957-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: