Provider Demographics
NPI:1255494977
Name:MOSS, DARYL A (DC)
Entity Type:Individual
Prefix:DR
First Name:DARYL
Middle Name:A
Last Name:MOSS
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 1:2110 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6475
Mailing Address - Country:US
Mailing Address - Phone:208-524-3018
Mailing Address - Fax:208-524-3019
Practice Address - Street 1:2110 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6475
Practice Address - Country:US
Practice Address - Phone:208-524-3018
Practice Address - Fax:208-524-3019
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA 896111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC1823OtherBLUE CROSS NUMBER
ID807164600Medicaid
ID000010028117OtherBLUE SHIELD #
ID000010028117OtherBLUE SHIELD #
IDC1823OtherBLUE CROSS NUMBER