Healthcare Provider Details

I. General information

NPI: 1063237642
Provider Name (Legal Business Name): BENJAMIN C MOYER II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 ALPINE DR
NAVARRE FL
32566-7695
US

IV. Provider business mailing address

2055 CASA DE ORO ST
NAVARRE FL
32566-7556
US

V. Phone/Fax

Practice location:
  • Phone: 850-939-3339
  • Fax: 850-939-1605
Mailing address:
  • Phone: 850-582-6729
  • Fax: 850-939-1605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA90688
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: