Healthcare Provider Details

I. General information

NPI: 1275070278
Provider Name (Legal Business Name): ANTHONY DICARLOS MOXLEY II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

018 SW BOUNDARY CT
PORTLAND OR
97239-3939
US

IV. Provider business mailing address

018 SW BOUNDARY CT
PORTLAND OR
97239-3939
US

V. Phone/Fax

Practice location:
  • Phone: 503-542-2762
  • Fax: 503-208-7160
Mailing address:
  • Phone: 503-542-2762
  • Fax: 503-208-7160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: