MEDICARE: TONY C MOFFETT SR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility
2	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1083190664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONY C MOFFETT SR.

Provider Business Mailing Address
First Line	:	6047 STILL MDW
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78222-3425
Country	:	US
Telephone Number	:	979-402-7937
Fax Number	:

Provider Business Practice Location Address
First Line	:	6047 STILL MDW
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78222-3425
Country	:	US
Telephone Number	:	979-402-7937
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2018
Last Update Date	:	07/17/2018

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