Provider Demographics
NPI:1043573223
Name:MORENO, RICARDO
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N RAUL LONGORIA RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-3720
Mailing Address - Country:US
Mailing Address - Phone:956-782-5800
Mailing Address - Fax:956-782-5802
Practice Address - Street 1:1205 N RAUL LONGORIA RD
Practice Address - Street 2:SUITE I
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-3720
Practice Address - Country:US
Practice Address - Phone:956-782-5800
Practice Address - Fax:956-782-5802
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210292224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210292OtherSTATE LICENSE