Provider Demographics
NPI:1467930909
Name:MOSES, SERRENA
Entity Type:Individual
Prefix:
First Name:SERRENA
Middle Name:
Last Name:MOSES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4818 ELMONT PL
Mailing Address - Street 2:
Mailing Address - City:GROVEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43125-9646
Mailing Address - Country:US
Mailing Address - Phone:614-747-0309
Mailing Address - Fax:
Practice Address - Street 1:7690 NEW MARKET CENTER WAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-1976
Practice Address - Country:US
Practice Address - Phone:614-602-6473
Practice Address - Fax:614-602-6493
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid