Provider Demographics
NPI:1962462903
Name:MOORE, PHILLIP (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:
Last Name:MOORE
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:PO BOX 1609
Mailing Address - Street 2:3609 HWY 367 N
Mailing Address - City:BALD KNOB
Mailing Address - State:AR
Mailing Address - Zip Code:72010-1609
Mailing Address - Country:US
Mailing Address - Phone:501-724-2202
Mailing Address - Fax:501-724-2202
Practice Address - Street 1:3609 HIGHWAY 367 N
Practice Address - Street 2:
Practice Address - City:BALD KNOB
Practice Address - State:AR
Practice Address - Zip Code:72010-9404
Practice Address - Country:US
Practice Address - Phone:501-724-2202
Practice Address - Fax:501-724-2202
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1083111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150110718Medicaid
AR5187337OtherAETNA
AR59073OtherBLUE CROSS
AR150110718Medicaid
AR5187337OtherAETNA