=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730344490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOSS ACHIEVEMENT CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2008
-----------------------------------------------------
Last Update Date | 10/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 ADLER CIR
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08048-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-220-9023
-----------------------------------------------------
Fax | 856-234-9100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 ADLER CIR
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08048-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-220-9023
-----------------------------------------------------
Fax | 856-234-9100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | JACQUELINE MOSS
-----------------------------------------------------
Credential | B.S.P.P.
-----------------------------------------------------
Telephone | 609-220-9023
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | PT40QA00500500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------