Provider Demographics
NPI:1760020549
Name:MORENO, MARVIN A
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:A
Last Name:MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MARVIN
Other - Middle Name:A
Other - Last Name:MORALES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:15 FLOCK LN
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-4114
Mailing Address - Country:US
Mailing Address - Phone:516-458-6677
Mailing Address - Fax:
Practice Address - Street 1:15 FLOCK LN
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-4114
Practice Address - Country:US
Practice Address - Phone:516-458-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336795-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse