Provider Demographics
NPI:1629750815
Name:MORENO, MARC ANDREW
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ANDREW
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 1:20323 GRESHAM ST
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-1122
Mailing Address - Country:US
Mailing Address - Phone:818-439-0182
Mailing Address - Fax:
Practice Address - Street 1:16300 ROSCOE BLVD STE A1
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-1246
Practice Address - Country:US
Practice Address - Phone:818-893-4426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304495225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist