Provider Demographics
NPI:1316123102
Name:MOSS CHIROPRACTIC CLINIC P.C.
Entity type:Organization
Organization Name:MOSS CHIROPRACTIC CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-468-5775
Mailing Address - Street 1:POB 224
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038
Mailing Address - Country:US
Mailing Address - Phone:269-468-5775
Mailing Address - Fax:269-468-3447
Practice Address - Street 1:429 N. PAW PAW STREET
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:MI
Practice Address - Zip Code:49038
Practice Address - Country:US
Practice Address - Phone:269-468-5775
Practice Address - Fax:269-468-3447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950A111480OtherBLUE CROSS BLUE SHIELD MI
MI950A111480OtherBLUE CROSS BLUE SHIELD MI