Provider Demographics
NPI:1437339132
Name:GEORGE R. MOON DC PA
Entity Type:Organization
Organization Name:GEORGE R. MOON DC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-261-1387
Mailing Address - Street 1:1190 PINE RIDGE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-8914
Mailing Address - Country:US
Mailing Address - Phone:239-261-1387
Mailing Address - Fax:239-263-8780
Practice Address - Street 1:1190 PINE RIDGE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-8914
Practice Address - Country:US
Practice Address - Phone:239-261-1387
Practice Address - Fax:239-263-8780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24818Medicare PIN