Provider Demographics
NPI:1912029604
Name:MOSS CHIROPRACTIC, P.A.
Entity Type:Organization
Organization Name:MOSS CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:I
Authorized Official - Credentials:DC
Authorized Official - Phone:208-527-3039
Mailing Address - Street 1:1278 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-5544
Mailing Address - Country:US
Mailing Address - Phone:208-524-3018
Mailing Address - Fax:208-524-3019
Practice Address - Street 1:1278 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5544
Practice Address - Country:US
Practice Address - Phone:208-524-3018
Practice Address - Fax:208-524-3019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-896111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010028117OtherBLUE SHIELD OF IDAHO
IDC1823OtherBLUE CROSS OF IDAHO
ID807164600Medicaid
IDC1823OtherBLUE CROSS OF IDAHO
ID1674183Medicare ID - Type UnspecifiedMEDICARE #