Provider Demographics
NPI:1407495021
Name:MOSS OPTICAL, LLC
Entity Type:Organization
Organization Name:MOSS OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:713-591-7781
Mailing Address - Street 1:4312 ABBOTT AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1415
Mailing Address - Country:US
Mailing Address - Phone:713-591-7781
Mailing Address - Fax:
Practice Address - Street 1:1568 N FARWELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-2639
Practice Address - Country:US
Practice Address - Phone:414-221-7055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center