Healthcare Provider Details

I. General information

NPI: 1306343561
Provider Name (Legal Business Name): MOAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 1ST AVE
SULPHUR LA
70663-3424
US

IV. Provider business mailing address

921 1ST AVE
SULPHUR LA
70663-3424
US

V. Phone/Fax

Practice location:
  • Phone: 337-527-6385
  • Fax: 337-527-3527
Mailing address:
  • Phone: 337-527-6385
  • Fax: 337-527-3527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10408R
License Number StateLA

VIII. Authorized Official

Name: BRIDGET VITA
Title or Position: ADMINISTRATOR
Credential:
Phone: 337-802-6936