Provider Demographics
NPI:1023069176
Name:MOORE, KEVIN JOEL (DC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOEL
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 1:2260 HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:GRAND MOUND
Mailing Address - State:IA
Mailing Address - Zip Code:52751-9509
Mailing Address - Country:US
Mailing Address - Phone:563-210-2839
Mailing Address - Fax:563-344-6060
Practice Address - Street 1:3420 ELMORE AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2594
Practice Address - Country:US
Practice Address - Phone:563-344-6060
Practice Address - Fax:563-344-6061
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAAO6100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1210096Medicaid
IA46875Medicare ID - Type Unspecified
IAU72651Medicare UPIN