Provider Demographics
NPI:1568906410
Name:MORENO, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MORENO
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 1:3761 STOCKER ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:VIEW PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90008-5111
Mailing Address - Country:US
Mailing Address - Phone:818-430-6042
Mailing Address - Fax:
Practice Address - Street 1:3761 STOCKER ST
Practice Address - Street 2:SUITE 106
Practice Address - City:VIEW PARK
Practice Address - State:CA
Practice Address - Zip Code:90008-5111
Practice Address - Country:US
Practice Address - Phone:818-430-6042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner