Provider Demographics
NPI:1669812970
Name:MOSS, CLARENCE J III (PT)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:J
Last Name:MOSS
Suffix:III
Gender:M
Credentials:PT
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 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-1417
Mailing Address - Fax:864-512-3719
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-512-1196
Practice Address - Fax:864-512-3719
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4358225100000X
GAPT002016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GANPI #OtherMEDCOST
GA003146226AMedicaid
GANPI #OtherBLUE CROSS OF GA
GA003146226AMedicaid