Healthcare Provider Details

I. General information

NPI: 1326797275
Provider Name (Legal Business Name): CHARLIE MOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2022
Last Update Date: 03/19/2022
Certification Date: 03/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 W EARLE AVE
YOUNGSTOWN OH
44511-1722
US

IV. Provider business mailing address

538 W EARLE AVE
YOUNGSTOWN OH
44511-1722
US

V. Phone/Fax

Practice location:
  • Phone: 330-318-2109
  • Fax:
Mailing address:
  • Phone: 330-318-2109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: