Provider Demographics
NPI:1932200110
Name:MOORE, JOHN KURT (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KURT
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 1:884 PORTOLA RD
Mailing Address - Street 2:A5
Mailing Address - City:PORTOLA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94028-7264
Mailing Address - Country:US
Mailing Address - Phone:650-851-4860
Mailing Address - Fax:650-851-4974
Practice Address - Street 1:884 PORTOLA RD
Practice Address - Street 2:A5
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-7264
Practice Address - Country:US
Practice Address - Phone:650-851-4860
Practice Address - Fax:650-851-4974
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19920111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADCO19920Medicare ID - Type UnspecifiedMEDICARE