Healthcare Provider Details

I. General information

NPI: 1154339661
Provider Name (Legal Business Name): MATHEW DAVID MOORE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E FLORIDA ST
HOLBROOK AZ
86025-2724
US

IV. Provider business mailing address

500 E FLORIDA ST
HOLBROOK AZ
86025-2724
US

V. Phone/Fax

Practice location:
  • Phone: 928-524-1900
  • Fax:
Mailing address:
  • Phone: 928-524-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5746AZ
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHR4245
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: