Provider Demographics
NPI:1558432831
Name:MOORE, KEVIN PATRICK (DC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:MOORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:CHIROPRACTIC AND
Other - Middle Name:ACUPUNCTURE
Other - Last Name:CENTER INC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2604 DEMPSTER ST
Mailing Address - Street 2:STE 304
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-8412
Mailing Address - Country:US
Mailing Address - Phone:847-635-8080
Mailing Address - Fax:847-390-8080
Practice Address - Street 1:2604 DEMPSTER ST
Practice Address - Street 2:STE 304
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-8412
Practice Address - Country:US
Practice Address - Phone:847-635-8080
Practice Address - Fax:847-390-8080
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005366111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-36062OtherBLUE CROSS BLUE SHIELD
IL1649460270OtherCORPORATE NPI
K14265OtherMEDICARE MEMBER NUMBER
IL016-36062OtherBLUE CROSS BLUE SHIELD
IL210839Medicare ID - Type Unspecified