Healthcare Provider Details

I. General information

NPI: 1386213551
Provider Name (Legal Business Name): RANDY E MOORE DC RDMSCRMSK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

758 W 100 S
HEBER CITY UT
84032-3739
US

IV. Provider business mailing address

758 W 100 S
HEBER CITY UT
84032-3739
US

V. Phone/Fax

Practice location:
  • Phone: 513-708-0585
  • Fax: 435-915-7223
Mailing address:
  • Phone: 513-708-0585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number12108828-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: