Provider Demographics
NPI:1710375522
Name:MORON, JUAN MIGUEL
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MIGUEL
Last Name:MORON
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 1:6120 39TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3644
Mailing Address - Country:US
Mailing Address - Phone:806-891-5951
Mailing Address - Fax:
Practice Address - Street 1:5301 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-4940
Practice Address - Country:US
Practice Address - Phone:806-793-5947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2100217225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant