Provider Demographics
NPI:1134285273
Name:MORENO, PEDRO SAUL (ATC)
Entity Type:Individual
Prefix:MR
First Name:PEDRO
Middle Name:SAUL
Last Name:MORENO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 MACEDONIA RD
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-9767
Mailing Address - Country:US
Mailing Address - Phone:601-545-8329
Mailing Address - Fax:
Practice Address - Street 1:1145 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-9740
Practice Address - Country:US
Practice Address - Phone:601-544-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT0038174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist