Provider Demographics
NPI:1720068026
Name:MOORE, J KENNETH (DC)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:KENNETH
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 1:707 SUNSET ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-2668
Mailing Address - Country:US
Mailing Address - Phone:940-383-9399
Mailing Address - Fax:940-566-8630
Practice Address - Street 1:707 SUNSET ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-2668
Practice Address - Country:US
Practice Address - Phone:940-383-9399
Practice Address - Fax:940-566-8630
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5766111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX088445401Medicaid
TX8S3560OtherBCBS ID NUMBER
TX00081ZMedicare PIN
TXU20720Medicare UPIN
TX088445401Medicaid