Healthcare Provider Details

I. General information

NPI: 1104545276
Provider Name (Legal Business Name): MOISE MOKET
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18316 MIDDLEBELT RD
LIVONIA MI
48152-5007
US

IV. Provider business mailing address

3355 W MIDDLEBURY DR
DEARBORN MI
48120-1186
US

V. Phone/Fax

Practice location:
  • Phone: 248-615-9730
  • Fax:
Mailing address:
  • Phone: 860-725-2940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: