Provider Demographics
NPI:1831851716
Name:MOORE, JOSHUA ROBERT (DC)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:ROBERT
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 1:400 SCHWEITZER PLAZA DR STE 4
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-9819
Mailing Address - Country:US
Mailing Address - Phone:208-265-9400
Mailing Address - Fax:
Practice Address - Street 1:400 SCHWEITZER PLAZA DR STE 4
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9819
Practice Address - Country:US
Practice Address - Phone:208-265-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61218822111N00000X
IDCHIA-2254111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor