Provider Demographics
NPI:1912076126
Name:DAVID R MOORE DC PC
Entity Type:Organization
Organization Name:DAVID R MOORE DC PC
Other - Org Name:ON TRACE REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-253-7005
Mailing Address - Street 1:850 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013
Mailing Address - Country:US
Mailing Address - Phone:973-253-7005
Mailing Address - Fax:
Practice Address - Street 1:850 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013
Practice Address - Country:US
Practice Address - Phone:973-253-7005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00543200111N00000X
NJ40QA01158600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ028058Medicare ID - Type Unspecified
U70223Medicare UPIN