Healthcare Provider Details

I. General information

NPI: 1376500413
Provider Name (Legal Business Name): BRIAN DAVID MOFFITT AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 03/31/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 W PARK DR STE 108
NORTH WILKESBORO NC
28659-3777
US

IV. Provider business mailing address

1915 W PARK DR STE 108
N WILKESBORO NC
28659-3777
US

V. Phone/Fax

Practice location:
  • Phone: 336-838-7758
  • Fax: 336-838-9790
Mailing address:
  • Phone: 336-838-7758
  • Fax: 336-838-9790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number6885
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number6885
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number6885
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: