Provider Demographics
NPI:1679558134
Name:MOSS, DAVID EARL (DC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:EARL
Last Name:MOSS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038-0224
Mailing Address - Country:US
Mailing Address - Phone:269-468-5775
Mailing Address - Fax:269-468-3447
Practice Address - Street 1:429 N PAW PAW ST
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:MI
Practice Address - Zip Code:49038-9567
Practice Address - Country:US
Practice Address - Phone:269-468-5775
Practice Address - Fax:269-468-3447
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004790111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
4430062OtherIBA UHC PHP
MI950A111470OtherBLUE CROSS BLUE SHIELD
MIDM004790OtherSTATE LICENSE NUMBER
MI12510467OtherMULTI PLAN
MI12510467OtherMULTI PLAN
MIDM004790OtherSTATE LICENSE NUMBER