Healthcare Provider Details

I. General information

NPI: 1689091902
Provider Name (Legal Business Name): MICHAEL V MOSS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 TOWNE LAKE PKWY
WOODSTOCK GA
30188-4843
US

IV. Provider business mailing address

180 TOWNE LAKE PKWY
WOODSTOCK GA
30188-4843
US

V. Phone/Fax

Practice location:
  • Phone: 770-517-2240
  • Fax:
Mailing address:
  • Phone: 770-517-2240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR009202
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: