Provider Demographics
NPI:1770399123
Name:MOSLEY, WATORIS (TRANSPORTER)
Entity type:Individual
Prefix:
First Name:WATORIS
Middle Name:
Last Name:MOSLEY
Suffix:
Gender:M
Credentials:TRANSPORTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8690 BROADWAY AVE
Mailing Address - Street 2:STE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7034
Mailing Address - Country:US
Mailing Address - Phone:708-679-4348
Mailing Address - Fax:
Practice Address - Street 1:8690 BROADWAY AVE
Practice Address - Street 2:STE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7034
Practice Address - Country:US
Practice Address - Phone:708-679-4348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN5370280407172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver