1063697662 NPI number — MOORE CHIROPRACTIC FAMILY CENTER

Table of content: (NPI 1063697662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063697662 NPI number — MOORE CHIROPRACTIC FAMILY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOORE CHIROPRACTIC FAMILY CENTER
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:
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:
1063697662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 N GILBERT ST
Provider Second Line Business Mailing Address:
PO BOX 495
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61832-5633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-443-2400
Provider Business Mailing Address Fax Number:
217-443-4199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 N GILBERT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61832-5633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-443-2400
Provider Business Practice Location Address Fax Number:
217-443-4199
Provider Enumeration Date:
01/02/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
TERRANCE
Authorized Official Middle Name:
WESLEY
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
217-443-2400

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  38003799 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 38003799 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9215161 . This is a "BLUECROSSBLUESHIELD OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".