Healthcare Provider Details

I. General information

NPI: 1538294897
Provider Name (Legal Business Name): DONALD E MOULTON RN OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 03/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WOODLAND DR
COOS BAY OR
97420-0000
US

IV. Provider business mailing address

1900 WOODLAND DR
COOS BAY OR
97420-0000
US

V. Phone/Fax

Practice location:
  • Phone: 541-267-5151
  • Fax: 541-266-4541
Mailing address:
  • Phone: 541-267-5151
  • Fax: 541-266-4541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number083026191RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License Number930064
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number930064 OT-SC
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: