Basic Information
| Provider Information | |||||||||
| NPI: | 1376784454 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOAT | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20280 N 59TH AVE | ||||||||
| Address2: | STE 115-617 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853086850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027958700 | ||||||||
| FaxNumber: | 6027958701 | ||||||||
| Practice Location | |||||||||
| Address1: | 7200 W BELL RD | ||||||||
| Address2: | STE F-101 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853088529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027958700 | ||||||||
| FaxNumber: | 6027958701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2009 | ||||||||
| LastUpdateDate: | 02/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 8030 | AZ | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 432456 | 05 | AZ | MEDICAID |