Provider Demographics
NPI:1467630194
Name:MOON CHIROPRACTIC CENTER, PLLC
Entity Type:Organization
Organization Name:MOON CHIROPRACTIC CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-753-1120
Mailing Address - Street 1:1751 STOCKTON HILL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6601
Mailing Address - Country:US
Mailing Address - Phone:928-753-1120
Mailing Address - Fax:928-753-6191
Practice Address - Street 1:1751 STOCKTON HILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-6601
Practice Address - Country:US
Practice Address - Phone:928-753-1120
Practice Address - Fax:928-753-6191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5153111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU45922Medicare UPIN
AZZDC5153Medicare PIN