Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | CH0003522 | FL |
NPI | 1003915257 |
---|---|
Provider Name | Dr. Ronald Budd Moussette JR. |
First Address | Lady Lake, FL 32159 |
Second Address | Lady Lake, FL 32159-4540 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 02/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
88756 | BCBS (01) | |
T55946 | (02) |