Healthcare Provider Details

I. General information

NPI: 1811042229
Provider Name (Legal Business Name): BRANDON MOORE CHIROPRACTIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 S COURT ST
GRAYVILLE IL
62844-1579
US

IV. Provider business mailing address

718 S COURT ST
GRAYVILLE IL
62844-1579
US

V. Phone/Fax

Practice location:
  • Phone: 618-375-2771
  • Fax:
Mailing address:
  • Phone: 618-375-2771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-010702
License Number StateIL

VIII. Authorized Official

Name: DR. BRANDON M MOORE
Title or Position: PRESIDENT
Credential: D.C.
Phone: 618-375-2771