Provider Demographics
NPI:1740213636
Name:MOORE, RICHARD CORY (DC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CORY
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 1:418 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-2620
Mailing Address - Country:US
Mailing Address - Phone:805-473-9404
Mailing Address - Fax:
Practice Address - Street 1:418 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2620
Practice Address - Country:US
Practice Address - Phone:805-473-9404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28985111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0289850OtherBLUE SHIELD
CAY01593Medicare UPIN
CADC0289850OtherBLUE SHIELD