Provider Demographics
NPI:1972037505
Name:MOULTON CHIROPRACTIC
Entity type:Organization
Organization Name:MOULTON CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAEL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:402-577-0566
Mailing Address - Street 1:2524 BEAR HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3880
Mailing Address - Country:US
Mailing Address - Phone:402-577-0566
Mailing Address - Fax:
Practice Address - Street 1:621 N MAIN ST
Practice Address - Street 2:SUITE 415 & 440
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-9213
Practice Address - Country:US
Practice Address - Phone:402-577-0566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13431111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty