Provider Demographics
NPI:1518358720
Name:MORENO, ELIJAH (RECOVERY ASSISTANT)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:RECOVERY ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N SHAMROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-9658
Mailing Address - Country:US
Mailing Address - Phone:501-315-3344
Mailing Address - Fax:
Practice Address - Street 1:210 N SHAMROCK BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-9658
Practice Address - Country:US
Practice Address - Phone:501-315-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator