Provider Demographics
NPI:1053615708
Name:DALE J MOSER
Entity type:Organization
Organization Name:DALE J MOSER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-386-2020
Mailing Address - Street 1:1520 N MCEWAN ST # B
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-1196
Mailing Address - Country:US
Mailing Address - Phone:989-386-2020
Mailing Address - Fax:989-386-7308
Practice Address - Street 1:1520 N MCEWAN ST
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617
Practice Address - Country:US
Practice Address - Phone:989-386-2020
Practice Address - Fax:989-386-7308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003085152W00000X
MI003085332H00000X
MI004640332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A86500OtherMEDICARE ID-INSPECIFIED
MI900A86500OtherBLUE CROSS BLUE SHIED
MI1769910Medicaid
MI1908862Medicaid
MI410008233OtherRAIL ROAD MEDICARE
MI2671940001Medicare NSC
MIT32688Medicare UPIN
MI1769910Medicaid