Provider Demographics
NPI:1215038161
Name:MOORE, BRANDON MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:MARK
Last Name:MOORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:958 S KENMORE DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-7513
Mailing Address - Country:US
Mailing Address - Phone:812-401-2140
Mailing Address - Fax:812-777-4501
Practice Address - Street 1:958 S KENMORE DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-7513
Practice Address - Country:US
Practice Address - Phone:812-401-2140
Practice Address - Fax:812-777-4501
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010702111N00000X
IN08002888A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor