Provider Demographics
NPI:1669852901
Name:MOORE, MICHAEL DARELL
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DARELL
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:DARELL
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:10850 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-1613
Mailing Address - Country:US
Mailing Address - Phone:913-234-0779
Mailing Address - Fax:
Practice Address - Street 1:10850 LOWELL AVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-1613
Practice Address - Country:US
Practice Address - Phone:913-234-0779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05149111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor