Provider Demographics
NPI:1316136823
Name:MOORE, WESLEY DALE (DC)
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:DALE
Last Name:MOORE
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 1:405 COOPER DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2817
Mailing Address - Country:US
Mailing Address - Phone:910-592-8848
Mailing Address - Fax:
Practice Address - Street 1:405 COOPER DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2817
Practice Address - Country:US
Practice Address - Phone:910-592-8848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-20
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1301111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC08633OtherBLUE CROSS BLUE SHIELD
244381Medicare PIN
NCT64427Medicare UPIN