Provider Demographics
NPI:1457421877
Name:MOORE, RANDALL B (DC)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:B
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 1:804 S HOOD ST
Mailing Address - Street 2:
Mailing Address - City:ALVIN
Mailing Address - State:TX
Mailing Address - Zip Code:77511-3459
Mailing Address - Country:US
Mailing Address - Phone:720-985-5372
Mailing Address - Fax:720-302-2522
Practice Address - Street 1:804 S HOOD ST
Practice Address - Street 2:
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511-3459
Practice Address - Country:US
Practice Address - Phone:720-985-5372
Practice Address - Fax:720-302-2522
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5595111N00000X
TX09118111N00000X
TX9118111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46-4309251OtherTAX ID#
TX9118OtherSTATE LICENSE
CO1457421877OtherNPI
COC-803306Medicare PIN