Provider Demographics
NPI:1538154620
Name:MOSES, JACK ALONZO JR (DC)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALONZO
Last Name:MOSES
Suffix:JR
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:PO BOX 183051
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48318-3051
Mailing Address - Country:US
Mailing Address - Phone:586-323-5060
Mailing Address - Fax:586-323-5062
Practice Address - Street 1:51210 ROMEO PLANK RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-4129
Practice Address - Country:US
Practice Address - Phone:586-323-5060
Practice Address - Fax:586-323-5062
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E01692OtherBLUECROSS
U74208Medicare UPIN
MIN4736006Medicare ID - Type Unspecified