Provider Demographics
NPI:1548036163
Name:MOORE, TRISTAN (DC)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
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 1:100 WILLOW CREEK PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-4387
Mailing Address - Country:US
Mailing Address - Phone:190-394-8084
Mailing Address - Fax:
Practice Address - Street 1:100 WILLOW CREEK PKWY STE C
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4387
Practice Address - Country:US
Practice Address - Phone:903-729-5051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15761111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor