Provider Demographics
NPI:1467778761
Name:MOSER, BLAKE (DC)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:MOSER
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 1:12086 FORT CAROLINE RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-2687
Mailing Address - Country:US
Mailing Address - Phone:904-564-2500
Mailing Address - Fax:904-564-2566
Practice Address - Street 1:12086 FORT CAROLINE RD
Practice Address - Street 2:SUITE 302
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-2687
Practice Address - Country:US
Practice Address - Phone:904-564-2500
Practice Address - Fax:904-564-2566
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 9926111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor