Provider Demographics
NPI:1326166018
Name:MORALES, JOHN ROBERT (CP, BOCO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:MORALES
Suffix:
Gender:M
Credentials:CP, BOCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-6616
Mailing Address - Country:US
Mailing Address - Phone:707-544-5347
Mailing Address - Fax:707-544-5349
Practice Address - Street 1:65 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-6616
Practice Address - Country:US
Practice Address - Phone:707-544-5347
Practice Address - Fax:707-544-5349
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXB0013930Medicaid
68-0179199OtherOTHER
68-0179199OtherOTHER