Provider Demographics
NPI:1912123480
Name:MOSS, VERNON (LOTR)
Entity Type:Individual
Prefix:MR
First Name:VERNON
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 KIOWA ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-8565
Mailing Address - Country:US
Mailing Address - Phone:318-557-1672
Mailing Address - Fax:318-345-2862
Practice Address - Street 1:109 KIOWA ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-8565
Practice Address - Country:US
Practice Address - Phone:318-557-1672
Practice Address - Fax:318-345-2862
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1434957Medicaid
LA4B340C989Medicare PIN