Provider Demographics
NPI:1063237642
Name:MOYER, BENJAMIN C II
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:C
Last Name:MOYER
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 CASA DE ORO ST
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-7556
Mailing Address - Country:US
Mailing Address - Phone:850-582-6729
Mailing Address - Fax:850-939-1605
Practice Address - Street 1:1816 ALPINE DR
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-7695
Practice Address - Country:US
Practice Address - Phone:850-939-3339
Practice Address - Fax:850-939-1605
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA90688225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist