Provider Demographics
NPI:1871663815
Name:MOON, PAUL DAEBOO (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DAEBOO
Last Name:MOON
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 1:10700 HIGHWAY 55 STE 100
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6130
Mailing Address - Country:US
Mailing Address - Phone:763-543-9080
Mailing Address - Fax:763-543-9082
Practice Address - Street 1:10700 HIGHWAY 55 STE 100
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6130
Practice Address - Country:US
Practice Address - Phone:763-543-9080
Practice Address - Fax:763-543-9082
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC3736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPC0272995Medicare ID - Type UnspecifiedCLINIC
MNU78005Medicare UPIN