Provider Demographics
NPI:1659928554
Name:MOSLEY, RUNDALL T
Entity type:Individual
Prefix:
First Name:RUNDALL
Middle Name:T
Last Name:MOSLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 W EDGEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5584
Mailing Address - Country:US
Mailing Address - Phone:417-824-5652
Mailing Address - Fax:
Practice Address - Street 1:3850 W EDGEWOOD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5584
Practice Address - Country:US
Practice Address - Phone:417-824-5652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-25
Last Update Date:2019-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty