Provider Demographics
NPI:1437368172
Name:JOHN B MOFFET DC PC
Entity Type:Organization
Organization Name:JOHN B MOFFET DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:MOFFET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-384-5678
Mailing Address - Street 1:216 COLLEGE AVE S
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2302
Mailing Address - Country:US
Mailing Address - Phone:912-384-5678
Mailing Address - Fax:
Practice Address - Street 1:216 COLLEGE AVE S
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2302
Practice Address - Country:US
Practice Address - Phone:912-384-5678
Practice Address - Fax:912-384-5510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002080111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000277197CMedicaid
GA35ZCJNBMedicare ID - Type UnspecifiedJOHN B MOFFET
GAGRP7588Medicare ID - Type UnspecifiedJOHN B MOFFET DC PC