Provider Demographics
NPI:1558565341
Name:MORENO, FELIXBERTO L (PTA)
Entity Type:Individual
Prefix:
First Name:FELIXBERTO
Middle Name:L
Last Name:MORENO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2267
Mailing Address - Country:US
Mailing Address - Phone:973-667-0017
Mailing Address - Fax:
Practice Address - Street 1:600 S LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5419
Practice Address - Country:US
Practice Address - Phone:800-278-0332
Practice Address - Fax:973-740-9007
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00157600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant