Healthcare Provider Details

I. General information

NPI: 1962462903
Provider Name (Legal Business Name): PHILLIP MOORE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3609 HIGHWAY 367 N
BALD KNOB AR
72010-9404
US

IV. Provider business mailing address

PO BOX 1609 3609 HWY 367 N
BALD KNOB AR
72010-1609
US

V. Phone/Fax

Practice location:
  • Phone: 501-724-2202
  • Fax: 501-724-2202
Mailing address:
  • Phone: 501-724-2202
  • Fax: 501-724-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1083
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: