=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477534287
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE M MOSELLE DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 CRONIN RD STE C
-----------------------------------------------------
City | QUEENSBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12804-1418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-615-0056
-----------------------------------------------------
Fax | 518-615-0059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 SAGAMORE ST SUITE B
-----------------------------------------------------
City | GLENS FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12801-3115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-615-0056
-----------------------------------------------------
Fax | 518-615-0059
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X0020861
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------