=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396758611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERRYL E MOON DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2006
-----------------------------------------------------
Last Update Date | 12/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 MAIN STREET
-----------------------------------------------------
City | FAIRMOUNT
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58030-0291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-474-5948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 291
-----------------------------------------------------
City | FAIRMOUNT
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58030-0291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-474-5948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 342
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------