Provider Demographics
NPI:1013377316
Name:MORENO, RICARDO (MS ATC CSCS)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:MS ATC CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 N NANTUCKET CT
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-1579
Mailing Address - Country:US
Mailing Address - Phone:480-250-3897
Mailing Address - Fax:
Practice Address - Street 1:7110 E MCKELLIPS RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-1908
Practice Address - Country:US
Practice Address - Phone:480-654-7726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ02812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer