Provider Demographics
NPI:1013085935
Name:ALVARO J MORENO OD PC
Entity Type:Organization
Organization Name:ALVARO J MORENO OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVARO
Authorized Official - Middle Name:J
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-549-1553
Mailing Address - Street 1:598 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2957
Mailing Address - Country:US
Mailing Address - Phone:601-450-3937
Mailing Address - Fax:601-909-6104
Practice Address - Street 1:598 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2957
Practice Address - Country:US
Practice Address - Phone:601-450-3937
Practice Address - Fax:601-909-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS610152W00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08637209Medicaid
4881550001Medicare NSC