Provider Demographics
NPI:1598828709
Name:MOORE, BRYAN EUGENE (DC)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:EUGENE
Last Name:MOORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 PONCE DE LEON DR
Mailing Address - Street 2:STE B
Mailing Address - City:HOT SPRINGS VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71909-8121
Mailing Address - Country:US
Mailing Address - Phone:501-915-9800
Mailing Address - Fax:
Practice Address - Street 1:412 PONCE DE LEON DR
Practice Address - Street 2:STE B
Practice Address - City:HOT SPRINGS VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71909-8121
Practice Address - Country:US
Practice Address - Phone:501-915-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4273111N00000X
AR15725111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR277861Medicare PIN