Provider Demographics
NPI:1700024080
Name:MORALES, STORM (LAC)
Entity Type:Individual
Prefix:MR
First Name:STORM
Middle Name:
Last Name:MORALES
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COUNTRY CLUB DRIVE
Mailing Address - Street 2:APT 1E
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727
Mailing Address - Country:US
Mailing Address - Phone:631-880-2336
Mailing Address - Fax:
Practice Address - Street 1:1 COUNTRY CLUB DR
Practice Address - Street 2:APT 1E
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-3405
Practice Address - Country:US
Practice Address - Phone:631-880-2336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004002171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist