Healthcare Provider Details

I. General information

NPI: 1053615708
Provider Name (Legal Business Name): DALE J MOSER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 N MCEWAN ST
CLARE MI
48617
US

IV. Provider business mailing address

1520 N MCEWAN ST # B
CLARE MI
48617-1196
US

V. Phone/Fax

Practice location:
  • Phone: 989-386-2020
  • Fax: 989-386-7308
Mailing address:
  • Phone: 989-386-2020
  • Fax: 989-386-7308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003085
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number003085
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number004640
License Number StateMI

VIII. Authorized Official

Name: DALE J MOSER
Title or Position: OWNER
Credential:
Phone: 989-386-2020