Provider Demographics
NPI:1346312865
Name:MOFFAT, MICHAEL R (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:MOFFAT
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 1:13945 E. MONO WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-2823
Mailing Address - Country:US
Mailing Address - Phone:209-532-3700
Mailing Address - Fax:209-532-4913
Practice Address - Street 1:13945 E. MONO WAY
Practice Address - Street 2:SUITE B
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-2823
Practice Address - Country:US
Practice Address - Phone:209-532-3700
Practice Address - Fax:209-532-4913
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14997111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA77-0364813OtherCORP TAX ID NUMBER
CAT05590Medicare UPIN
CADC0149970Medicare ID - Type Unspecified