MEDICARE: DR. BLAKE MOSER 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 9926	FL

General Provider Information

NPI Number	:	1467778761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE MOSER D.C.

Provider Business Mailing Address
First Line	:	12086 FORT CAROLINE RD
Second Line	:	SUITE 302
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-2687
Country	:	US
Telephone Number	:	904-564-2500
Fax Number	:	904-564-2566

Provider Business Practice Location Address
First Line	:	12086 FORT CAROLINE RD
Second Line	:	SUITE 302
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-2687
Country	:	US
Telephone Number	:	904-564-2500
Fax Number	:	904-564-2566

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

Provider Enumeration Date	:	04/12/2010
Last Update Date	:	02/15/2011

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