Provider Demographics
NPI:1811731987
Name:MCDONALD-MOORE, CHIQUETA M
Entity type:Individual
Prefix:
First Name:CHIQUETA
Middle Name:M
Last Name:MCDONALD-MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 ROMENCE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3437
Mailing Address - Country:US
Mailing Address - Phone:616-366-1889
Mailing Address - Fax:
Practice Address - Street 1:536 ROMENCE RD STE 106
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3437
Practice Address - Country:US
Practice Address - Phone:616-366-1889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-22
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI277011661991744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty