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General NPI Number Information
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NPI Number | 1780940221
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Entity Type | Organization
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Legal Business Name | MOON CHIROPRACTIC CLINIC
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Dates
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Enumeration Date | 04/10/2012
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Last Update Date | 04/10/2012
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Provider Practice Location Address
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Address Line | 110 MAIN AVE.
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City | FAIRMOUNT
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State | ND
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Zip | 58030
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Country | US
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Telephone | 701-474-5948
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 291
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City | FAIRMOUNT
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State | ND
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Zip | 58030-0291
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. DERRYL MOON
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Credential | DC
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Telephone | 701-474-5948
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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