Provider Demographics
NPI:1063160836
Name:MOULDS, SAMUEL WAYNE (LMT)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:WAYNE
Last Name:MOULDS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 E LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3155
Mailing Address - Country:US
Mailing Address - Phone:701-740-0551
Mailing Address - Fax:
Practice Address - Street 1:612 W LAUREL ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-3620
Practice Address - Country:US
Practice Address - Phone:701-740-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0023620225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist