Healthcare Provider Details

I. General information

NPI: 1548535933
Provider Name (Legal Business Name): MR. DAVID T. MOSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2012
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4641 FULTON DR NW
CANTON OH
44718-2384
US

IV. Provider business mailing address

4641 FULTON DR NW
CANTON OH
44718-2384
US

V. Phone/Fax

Practice location:
  • Phone: 330-433-6075
  • Fax: 330-433-1843
Mailing address:
  • Phone: 330-433-6075
  • Fax: 330-433-1843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.1200083-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: