Healthcare Provider Details

I. General information

NPI: 1699259655
Provider Name (Legal Business Name): MOCA ORSO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 06/03/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4007 SKIPPACK PIKE
SKIPPACK PA
19474-0196
US

IV. Provider business mailing address

952 N 3RD ST APT 601
PHILADELPHIA PA
19123
US

V. Phone/Fax

Practice location:
  • Phone: 610-584-7284
  • Fax:
Mailing address:
  • Phone: 412-599-1039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GREGORY BOLTON JR.
Title or Position: OWNER
Credential: MD
Phone: 412-599-1039