Provider Demographics
NPI:1417361619
Name:MORALES, JOHNNY
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:MORALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 SE LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:OR
Mailing Address - Zip Code:97115-9630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 E 2ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-3083
Practice Address - Country:US
Practice Address - Phone:503-476-6776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20484225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist