Provider Demographics
NPI:1811042229
Name:BRANDON MOORE CHIROPRACTIC P.C.
Entity Type:Organization
Organization Name:BRANDON MOORE CHIROPRACTIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-375-2771
Mailing Address - Street 1:718 S COURT ST
Mailing Address - Street 2:
Mailing Address - City:GRAYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62844-1579
Mailing Address - Country:US
Mailing Address - Phone:618-375-2771
Mailing Address - Fax:
Practice Address - Street 1:718 S COURT ST
Practice Address - Street 2:
Practice Address - City:GRAYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62844-1579
Practice Address - Country:US
Practice Address - Phone:618-375-2771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010702111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214697Medicare PIN