Provider Demographics
NPI:1235222811
Name:MOON, GEORGE R (DC)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:R
Last Name:MOON
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 1:1190 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-8914
Mailing Address - Country:US
Mailing Address - Phone:239-261-1387
Mailing Address - Fax:239-263-8780
Practice Address - Street 1:1190 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-8914
Practice Address - Country:US
Practice Address - Phone:239-261-1387
Practice Address - Fax:239-263-8780
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0002882111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88366OtherBLUE CROSS BLUE SHIELD
FL88366OtherBLUE CROSS BLUE SHIELD
FLT85848Medicare UPIN