Provider Demographics
NPI:1205950680
Name:MOSS, KENNETH (CSA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:CSA
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 888235
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30356-0235
Mailing Address - Country:US
Mailing Address - Phone:404-310-2321
Mailing Address - Fax:404-985-1694
Practice Address - Street 1:2602 FALL CREEK LDG
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5877
Practice Address - Country:US
Practice Address - Phone:404-310-2321
Practice Address - Fax:404-985-1694
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1558246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1558Other1558