Provider Demographics
NPI:1851456487
Name:MOORE, MICHAEL JASON (DC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JASON
Last Name:MOORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:JASON
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-0790
Mailing Address - Country:US
Mailing Address - Phone:928-645-0945
Mailing Address - Fax:928-645-3254
Practice Address - Street 1:463 S LAKE POWELL BLVD
Practice Address - Street 2:STE. A
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0790
Practice Address - Country:US
Practice Address - Phone:928-645-0945
Practice Address - Fax:928-645-3254
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5032111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZDC5032Medicare ID - Type UnspecifiedMEDICARE NUMBER