Provider Demographics
NPI:1639227929
Name:MORENO, DOMINIC L (MED, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:L
Last Name:MORENO
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2270 MEADOWLAKE RD
Mailing Address - Street 2:APT 808
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-2562
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:128 UCA PRINCE CTR
Practice Address - Street 2:201 DONAGHEY
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72035-0001
Practice Address - Country:US
Practice Address - Phone:501-852-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT 3862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer