Provider Demographics
NPI:1952476772
Name:MOORE, DEREK RIDDICK (CHIROPRACTOR)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:RIDDICK
Last Name:MOORE
Suffix:
Gender:M
Credentials:CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8996 SEMINOLE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-3850
Mailing Address - Country:US
Mailing Address - Phone:727-391-2602
Mailing Address - Fax:727-393-5479
Practice Address - Street 1:8996 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-3850
Practice Address - Country:US
Practice Address - Phone:727-391-2602
Practice Address - Fax:727-393-5479
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0004179111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor