1760734149 NPI number — RAE ANN MOXLEY

Table of content: (NPI 1760734149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760734149 NPI number — RAE ANN MOXLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAE ANN MOXLEY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760734149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
459 CONIFER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBBY
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59923-2966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-295-9980
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
459 CONIFER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBBY
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59923-2966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-295-9980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MOXLEY
Authorized Official First Name:
RAE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
406-293-9980

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  0044364-001 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0044364-001 . This is a "MT ST DEPT. OF PUBLIC HEALTH AND HUMAN SERVICES LICENSE FOR ADULT FOSTER HOME" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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