Healthcare Provider Details

I. General information

NPI: 1891050068
Provider Name (Legal Business Name): MARK LEE MOSS P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 10/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 E PARKCENTER BLVD SUITE 130
BOISE ID
83706-6662
US

IV. Provider business mailing address

16083 SW UPPER BOONES FERRY RD SUITE 300
TIGARD OR
97224-7736
US

V. Phone/Fax

Practice location:
  • Phone: 208-433-9211
  • Fax: 208-433-9241
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-639-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 3018
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: