Provider Demographics
NPI:1285636845
Name:MOORE, DANIEL GERALD (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:GERALD
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 1:19260 EVANS ST NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1076
Mailing Address - Country:US
Mailing Address - Phone:763-441-7788
Mailing Address - Fax:763-441-8818
Practice Address - Street 1:19332 HIGHWAY 169
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-4645
Practice Address - Country:US
Practice Address - Phone:763-441-7788
Practice Address - Fax:763-441-8818
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN003531111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1990917OtherFIRST HEALTH
MN421027100Medicaid
MN75B35MOOtherBLUECROSS BLUESHIELD
MN350002412Medicare ID - Type Unspecified
U67089Medicare UPIN