Provider Demographics
NPI:1396946406
Name:MOAT, GERALDINE BERNADETTE (DC)
Entity type:Individual
Prefix:DR
First Name:GERALDINE
Middle Name:BERNADETTE
Last Name:MOAT
Suffix:
Gender:F
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 159
Mailing Address - Street 2:
Mailing Address - City:GRAND LAKE
Mailing Address - State:CO
Mailing Address - Zip Code:80447-0159
Mailing Address - Country:US
Mailing Address - Phone:970-627-2418
Mailing Address - Fax:970-627-2418
Practice Address - Street 1:474 CR 48
Practice Address - Street 2:
Practice Address - City:GRAND LAKE
Practice Address - State:CO
Practice Address - Zip Code:80447
Practice Address - Country:US
Practice Address - Phone:970-627-2418
Practice Address - Fax:970-627-2418
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCO6034679Medicaid
TXCO6034679Medicaid
TXU20453Medicare UPIN