Provider Demographics
NPI:1992813505
Name:MOORE, CLINTON C (DC)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:C
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:PO BOX 1471
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74352-1471
Mailing Address - Country:US
Mailing Address - Phone:918-479-2827
Mailing Address - Fax:918-479-2817
Practice Address - Street 1:413 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:OK
Practice Address - Zip Code:74352
Practice Address - Country:US
Practice Address - Phone:918-479-2827
Practice Address - Fax:918-479-2817
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3649111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor