Provider Demographics
NPI:1598092918
Name:MORENO, DIANA (MSPT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 254
Mailing Address - Street 2:
Mailing Address - City:CHINA GROVE
Mailing Address - State:NC
Mailing Address - Zip Code:28023-0254
Mailing Address - Country:US
Mailing Address - Phone:704-210-6918
Mailing Address - Fax:704-210-6948
Practice Address - Street 1:514 CORPORATE CIR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-8074
Practice Address - Country:US
Practice Address - Phone:704-210-6918
Practice Address - Fax:704-210-6948
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC58672251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic