Provider Demographics
NPI:1366458440
Name:MOORMAN, J. RYAN (DC)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:RYAN
Last Name:MOORMAN
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 1:2804C N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1716
Mailing Address - Country:US
Mailing Address - Phone:229-241-8925
Mailing Address - Fax:229-241-7672
Practice Address - Street 1:2804C N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1716
Practice Address - Country:US
Practice Address - Phone:229-241-8925
Practice Address - Fax:229-241-7672
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006862111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCHZZMedicare ID - Type Unspecified
GAU96032Medicare UPIN