Healthcare Provider Details

I. General information

NPI: 1568066827
Provider Name (Legal Business Name): HUNTER MOSS HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2020
Last Update Date: 11/27/2020
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5383 EHRLICH RD
TAMPA FL
33625-5529
US

IV. Provider business mailing address

1415 W HIGHWAY 50
O FALLON IL
62269-1618
US

V. Phone/Fax

Practice location:
  • Phone: 813-269-2500
  • Fax:
Mailing address:
  • Phone: 618-624-4471
  • Fax: 618-624-4496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAST956
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: