Provider Demographics
NPI:1073818837
Name:MOORE, JAMES BLAINE (D C)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BLAINE
Last Name:MOORE
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31091
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-0091
Mailing Address - Country:US
Mailing Address - Phone:314-249-9361
Mailing Address - Fax:
Practice Address - Street 1:372 LADUEMONT DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8056
Practice Address - Country:US
Practice Address - Phone:314-249-9361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002025278111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor