Provider Demographics
NPI:1134207491
Name:MOONEYHAM, RICHARD C (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:MOONEYHAM
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 1:1655 BROAD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-7303
Mailing Address - Country:US
Mailing Address - Phone:803-772-8680
Mailing Address - Fax:803-772-5241
Practice Address - Street 1:1655 BROAD RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-7303
Practice Address - Country:US
Practice Address - Phone:803-772-8680
Practice Address - Fax:803-772-5241
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC618111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCHO618Medicaid
SCT23794Medicare UPIN
SCT237948475Medicare ID - Type Unspecified