Provider Demographics
NPI:1588689012
Name:MOORE, DEMETRA DIAN (DC)
Entity type:Individual
Prefix:DR
First Name:DEMETRA
Middle Name:DIAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 SE 93RD STREET
Mailing Address - Street 2:
Mailing Address - City:WAKARUSA
Mailing Address - State:KS
Mailing Address - Zip Code:66546
Mailing Address - Country:US
Mailing Address - Phone:785-438-0808
Mailing Address - Fax:785-234-2405
Practice Address - Street 1:1251 SW ARROWHEAD RD STE 101
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-4061
Practice Address - Country:US
Practice Address - Phone:785-806-8049
Practice Address - Fax:785-329-4785
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05208111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO231978OtherGROUP HEALTH PLAN
MO689477OtherHEALTHLINK
MO194726OtherBLUE CROSS BLUE SHIELD