Healthcare Provider Details

I. General information

NPI: 1952031585
Provider Name (Legal Business Name): BRIAN MOSELLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 1ST AVE NE
BUFFALO MN
55313-1515
US

IV. Provider business mailing address

2254 5TH ST SE
BUFFALO MN
55313-4803
US

V. Phone/Fax

Practice location:
  • Phone: 612-964-7700
  • Fax:
Mailing address:
  • Phone: 612-964-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: