Provider Demographics
NPI:1871663344
Name:MOSS, SERRA (DC)
Entity Type:Individual
Prefix:DR
First Name:SERRA
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 WESTCLIFF DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5524
Mailing Address - Country:US
Mailing Address - Phone:949-722-1955
Mailing Address - Fax:949-722-9555
Practice Address - Street 1:1617 WESTCLIFF DR
Practice Address - Street 2:SUITE 202
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5524
Practice Address - Country:US
Practice Address - Phone:949-722-1955
Practice Address - Fax:949-722-9555
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 24521111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC24521Medicare ID - Type Unspecified
CAU63403Medicare UPIN