Provider Demographics
NPI:1992139513
Name:MOSS, MICHAEL L
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:MOSS
Suffix:
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 1:935 PINEY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:WHIGHAM
Mailing Address - State:GA
Mailing Address - Zip Code:39897-3125
Mailing Address - Country:US
Mailing Address - Phone:229-762-4675
Mailing Address - Fax:229-762-4675
Practice Address - Street 1:935 PINEY GROVE RD
Practice Address - Street 2:
Practice Address - City:WHIGHAM
Practice Address - State:GA
Practice Address - Zip Code:39897-3125
Practice Address - Country:US
Practice Address - Phone:229-762-4675
Practice Address - Fax:229-762-4675
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator