Healthcare Provider Details

I. General information

NPI: 1548796428
Provider Name (Legal Business Name): MOES FAMILY PRACTICE AND KIDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 LAKELAND HILLS BLVD
LAKELAND FL
33805-3205
US

IV. Provider business mailing address

1507 LAKELAND HILLS BLVD
LAKELAND FL
33805-3205
US

V. Phone/Fax

Practice location:
  • Phone: 863-937-7578
  • Fax:
Mailing address:
  • Phone: 863-937-7578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State

VIII. Authorized Official

Name: GARVI R ARIAS
Title or Position: OWNER
Credential:
Phone: 863-937-7578