Provider Demographics
NPI:1063697662
Name:MOORE CHIROPRACTIC FAMILY CENTER
Entity type:Organization
Organization Name:MOORE CHIROPRACTIC FAMILY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:217-443-2400
Mailing Address - Street 1:425 N GILBERT ST
Mailing Address - Street 2:PO BOX 495
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-5633
Mailing Address - Country:US
Mailing Address - Phone:217-443-2400
Mailing Address - Fax:217-443-4199
Practice Address - Street 1:425 N GILBERT ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5633
Practice Address - Country:US
Practice Address - Phone:217-443-2400
Practice Address - Fax:217-443-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38003799111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL38003799Medicaid
IL9215161OtherBLUECROSSBLUESHIELD OF IL
IL9215161OtherBLUECROSSBLUESHIELD OF IL