=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598944779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOORE ABUNDANT LIFE CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2007
-----------------------------------------------------
Last Update Date | 05/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4008 GATEWAY DR SUITE 180
-----------------------------------------------------
City | COLLEYVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76034-7914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-571-9700
-----------------------------------------------------
Fax | 817-358-0219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4008 GATEWAY DR SUITE 180
-----------------------------------------------------
City | COLLEYVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76034-7914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-571-9700
-----------------------------------------------------
Fax | 817-358-0219
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JASON NICHOLAS MOORE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 817-358-0209
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 10451
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------