Healthcare Provider Details

I. General information

NPI: 1497070080
Provider Name (Legal Business Name): JAMES BRIAN MOELLER MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 04/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE TRAVERSE DRIVE
SISSETON SD
57262
US

IV. Provider business mailing address

100 LAKE TRAVERSE DRIVE
SISSETON SD
57262
US

V. Phone/Fax

Practice location:
  • Phone: 605-742-3792
  • Fax:
Mailing address:
  • Phone: 605-742-3792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number189324
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: