Healthcare Provider Details

I. General information

NPI: 1174003297
Provider Name (Legal Business Name): LESLIE MOSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 ASHLEY
EDDY TX
76524-3210
US

IV. Provider business mailing address

PO BOX 568
BELTON TX
76513-0568
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 254-939-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: