Provider Demographics
NPI:1821357468
Name:MOORE, DAVID JOHN (LAC, CMT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:MOORE
Suffix:
Gender:M
Credentials:LAC, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 LEHIGH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80305-6352
Mailing Address - Country:US
Mailing Address - Phone:303-917-3318
Mailing Address - Fax:
Practice Address - Street 1:1210 LEHIGH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-6352
Practice Address - Country:US
Practice Address - Phone:303-917-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODORA # 1749171100000X
CONCCAOM # 150098171100000X
CODORA # 5298171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist