MEDICARE: TIFFANY NICOLE MOULTERIE D.C

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	111N00000X	Chiropractor	CH 10787	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295171361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY NICOLE MOULTERIE D.C

Provider Business Mailing Address
First Line	:	2610 N MARKET ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-2958
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1660 BLANDING BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-1835
Country	:	US
Telephone Number	:	904-389-3811
Fax Number	:

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

Provider Enumeration Date	:	05/16/2013
Last Update Date	:	08/27/2014

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