Provider Demographics
NPI:1649764697
Name:MOFFETT CHIROPRACTIC
Entity Type:Organization
Organization Name:MOFFETT CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOFFETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-937-3509
Mailing Address - Street 1:607 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2537
Mailing Address - Country:US
Mailing Address - Phone:618-937-3509
Mailing Address - Fax:618-937-3500
Practice Address - Street 1:607 W OAK ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896
Practice Address - Country:US
Practice Address - Phone:618-937-3509
Practice Address - Fax:618-937-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009210111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty