Provider Demographics
NPI:1417153438
Name:MANUEL V MORENO
Entity Type:Organization
Organization Name:MANUEL V MORENO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-322-9948
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-0056
Mailing Address - Country:US
Mailing Address - Phone:570-323-8091
Mailing Address - Fax:570-322-6195
Practice Address - Street 1:215 E WATER ST
Practice Address - Street 2:
Practice Address - City:MUNCY
Practice Address - State:PA
Practice Address - Zip Code:17756-8828
Practice Address - Country:US
Practice Address - Phone:570-322-9948
Practice Address - Fax:570-322-6195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038231L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010564680003Medicaid
PA0010564680003Medicaid
PAC31745Medicare UPIN