=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154702397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. PHILLIP MOISE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2015
-----------------------------------------------------
Last Update Date | 06/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2881 CASTRO VALLEY BLVD STE 3
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-5567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-582-3707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2881 CASTRO VALLEY BLVD STE 3
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-5567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-582-3707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------