=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164739637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOELLMER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2010
-----------------------------------------------------
Last Update Date | 09/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1212 N PARK AVE
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91768-3029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-623-4484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1212 N PARK AVE
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91768-3029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | REBECCA MOELLMER
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 310-766-0200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | E4602
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------