Provider Demographics
NPI:1831285568
Name:MOORE, CONSTANCE MAE (DC)
Entity Type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:MAE
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 1:310 N. BROADWAY
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901
Mailing Address - Country:US
Mailing Address - Phone:505-894-6457
Mailing Address - Fax:505-894-6457
Practice Address - Street 1:310 N. BROADWAY
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901
Practice Address - Country:US
Practice Address - Phone:505-894-6457
Practice Address - Fax:505-894-6457
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1573111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor