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General NPI Number Information
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NPI Number | 1154789436
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Entity Type | Organization
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Legal Business Name | RICHARD MOSS MD
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Dates
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Enumeration Date | 02/02/2016
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Last Update Date | 02/02/2016
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Provider Practice Location Address
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Address Line | 721 W 13TH ST SUITE 208
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City | JASPER
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State | IN
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Zip | 47546-1855
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Country | US
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Telephone | 812-634-6666
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Fax | 812-634-6669
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Provider Business Mailing Address
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Address Line | 721 W 13TH ST SUITE 208
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City | JASPER
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State | IN
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Zip | 47546-1855
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Country | US
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Telephone | 812-634-6666
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Fax | 812-634-6669
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LISA YUCATONIS
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Credential | LPN
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Telephone | 812-634-6666
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 01039795A
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License Number State | IN
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