Provider Demographics
NPI:1407373814
Name:MORENO, TERESITA
Entity Type:Individual
Prefix:
First Name:TERESITA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15605 SW 178TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-7805
Mailing Address - Country:US
Mailing Address - Phone:305-968-7525
Mailing Address - Fax:305-253-3027
Practice Address - Street 1:15605 SW 178TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33187-7805
Practice Address - Country:US
Practice Address - Phone:305-968-7525
Practice Address - Fax:305-253-3027
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001878300Medicaid
FL688419998Medicaid
FL688419996Medicaid