Provider Demographics
NPI:1073275368
Name:MORENO, ROBERTO ANTONIO (RN)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:ANTONIO
Last Name:MORENO
Suffix:
Gender:M
Credentials:RN
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 752
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:IN
Mailing Address - Zip Code:46394-0752
Mailing Address - Country:US
Mailing Address - Phone:219-999-5869
Mailing Address - Fax:
Practice Address - Street 1:2462 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:IN
Practice Address - Zip Code:46394-2157
Practice Address - Country:US
Practice Address - Phone:219-999-5869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN21-015157372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion