Provider Demographics
NPI:1316016967
Name:MOORE, GARY CARL (DC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:CARL
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 1:256 ROSKOVENSKY RD
Mailing Address - Street 2:
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-5489
Mailing Address - Country:US
Mailing Address - Phone:724-454-9500
Mailing Address - Fax:724-532-5303
Practice Address - Street 1:256 ROSKOVENSKY RD
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-5489
Practice Address - Country:US
Practice Address - Phone:724-454-9500
Practice Address - Fax:724-532-5303
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-001546-L111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006348610003Medicaid
PA151626Medicare ID - Type Unspecified