Provider Demographics
NPI:1023665932
Name:MORENO, MATTHEW JOSEPH
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:MORENO
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 1:5711 JEFFERSON ST APT 210
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-1118
Mailing Address - Country:US
Mailing Address - Phone:201-275-3079
Mailing Address - Fax:
Practice Address - Street 1:2002 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-4431
Practice Address - Country:US
Practice Address - Phone:201-608-3124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2024-08-21
Deactivation Date:2024-02-05
Deactivation Code:
Reactivation Date:2024-07-12
Provider Licenses
StateLicense IDTaxonomies
225200000X
NJ18KT01491500225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant