Provider Demographics
NPI:1720150188
Name:MOORE, STEVEN JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:JOHN
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 1:210 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-2036
Mailing Address - Country:US
Mailing Address - Phone:507-934-4385
Mailing Address - Fax:
Practice Address - Street 1:220 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-2036
Practice Address - Country:US
Practice Address - Phone:507-934-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2014111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN69D71MOOtherBLUE CROSS BLUE SHIELD
MN82532770Medicare ID - Type Unspecified
MN69D71MOOtherBLUE CROSS BLUE SHIELD