Provider Demographics
NPI:1568541654
Name:EDWIN B MOSS
Entity Type:Organization
Organization Name:EDWIN B MOSS
Other - Org Name:MOSS EYECARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:BURNETT
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:318-539-5905
Mailing Address - Street 1:207 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGHILL
Mailing Address - State:LA
Mailing Address - Zip Code:71075-3303
Mailing Address - Country:US
Mailing Address - Phone:318-539-5905
Mailing Address - Fax:318-539-5908
Practice Address - Street 1:207 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:SPRINGHILL
Practice Address - State:LA
Practice Address - Zip Code:71075-3303
Practice Address - Country:US
Practice Address - Phone:318-539-5905
Practice Address - Fax:318-539-5908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA918096T332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1316620002OtherDMERC
LA1363871Medicaid
LA1363871Medicaid
TI9485Medicare UPIN