Basic Information
| Provider Information | |||||||||
| NPI: | 1972883536 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOELLMER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1762 N WATERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098863668 | ||||||||
| FaxNumber: | 9098865542 | ||||||||
| Practice Location | |||||||||
| Address1: | 1762 N WATERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098863668 | ||||||||
| FaxNumber: | 9098865542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2011 | ||||||||
| LastUpdateDate: | 08/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | MOELLMER | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3107660200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | E4602 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.