Provider Demographics
NPI:1144686445
Name:MOSS, ROBERT (ATC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 OKEEFE RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1354
Mailing Address - Country:US
Mailing Address - Phone:269-274-5597
Mailing Address - Fax:
Practice Address - Street 1:906 OKEEFE RD
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1354
Practice Address - Country:US
Practice Address - Phone:269-274-5597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI36541332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer