Provider Demographics
NPI:1215447438
Name:MOORE & MENNETO CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:MOORE & MENNETO CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:479-466-7717
Mailing Address - Street 1:6910 VINTAGE LANE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128
Mailing Address - Country:US
Mailing Address - Phone:386-202-2714
Mailing Address - Fax:386-202-2708
Practice Address - Street 1:3959 S NOVA RD
Practice Address - Street 2:STE 9
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127
Practice Address - Country:US
Practice Address - Phone:386-202-2714
Practice Address - Fax:386-202-2708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9865111N00000X
FLCH11081111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty