Provider Demographics
NPI:1366630071
Name:MOORE, WILLOW (DC, ND)
Entity Type:Individual
Prefix:DR
First Name:WILLOW
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:DC, ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 560
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-0560
Mailing Address - Country:US
Mailing Address - Phone:425-314-2745
Mailing Address - Fax:360-263-4351
Practice Address - Street 1:4916 NE ST JOHNS RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-2547
Practice Address - Country:US
Practice Address - Phone:360-694-4811
Practice Address - Fax:360-263-4351
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT435111N00000X
OR570175F00000X
WANT00001012175F00000X
WACH60062846111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No111N00000XChiropractic ProvidersChiropractor