Provider Demographics
NPI:1194701862
Name:MOS LLC
Entity type:Organization
Organization Name:MOS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:850-973-4590
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32341
Mailing Address - Country:US
Mailing Address - Phone:850-973-4590
Mailing Address - Fax:850-973-4929
Practice Address - Street 1:256 SW WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340
Practice Address - Country:US
Practice Address - Phone:850-973-4590
Practice Address - Fax:850-973-4929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1396122363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY1305OtherBCBS
FLP24380Medicare UPIN