Provider Demographics
NPI:1639345283
Name:MOORE, CAMILLA SUSAN (DC)
Entity Type:Individual
Prefix:DR
First Name:CAMILLA
Middle Name:SUSAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-2003
Mailing Address - Country:US
Mailing Address - Phone:617-669-3008
Mailing Address - Fax:
Practice Address - Street 1:144 WATERMAN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2126
Practice Address - Country:US
Practice Address - Phone:401-396-2010
Practice Address - Fax:410-466-4050
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2012-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3187111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor