Provider Demographics
NPI:1770143802
Name:MOORE, TAYLOR (DC)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
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 1:6629 UNIVERSITY AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3037
Mailing Address - Country:US
Mailing Address - Phone:920-379-7268
Mailing Address - Fax:
Practice Address - Street 1:6629 UNIVERSITY AVE STE 101
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562
Practice Address - Country:US
Practice Address - Phone:920-379-7268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5456111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor