Provider Demographics
NPI:1306862636
Name:MOONEY, BRENT M (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:M
Last Name:MOONEY
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 1:1980 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-9001
Mailing Address - Country:US
Mailing Address - Phone:530-622-3536
Mailing Address - Fax:530-622-3538
Practice Address - Street 1:1980 BROADWAY
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-9001
Practice Address - Country:US
Practice Address - Phone:530-622-3536
Practice Address - Fax:530-622-3538
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29028111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGDC000640Medicaid
CAGDC000640Medicaid
CADC0290280Medicare ID - Type UnspecifiedINDIV. PROVIDER NUMBER
CAYYY49788YMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER