Provider Demographics
NPI:1124315825
Name:MOEN, GREG (DC)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:
Last Name:MOEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7731 W MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-1150
Mailing Address - Country:US
Mailing Address - Phone:414-327-7913
Mailing Address - Fax:
Practice Address - Street 1:7731 W MORGAN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-1150
Practice Address - Country:US
Practice Address - Phone:414-327-7913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3631-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor