MEDICARE: MOSE MAST

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	171W00000X	Contractor		VA

General Provider Information

NPI Number	:	1588865612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOSE MAST

Provider Business Mailing Address
First Line	:	506 VIKING DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-7316
Country	:	US
Telephone Number	:	757-304-0686
Fax Number	:	757-340-1393

Provider Business Practice Location Address
First Line	:	506 VIKING DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-7316
Country	:	US
Telephone Number	:	757-304-0686
Fax Number	:	757-340-1393

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

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	07/08/2007

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Directions to “ MOSE MAST ” Practice Location

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