Provider Demographics
NPI:1023670791
Name:MORENO, REGINO (LMT)
Entity type:Individual
Prefix:
First Name:REGINO
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9425 IRENE AVE
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93505-1216
Mailing Address - Country:US
Mailing Address - Phone:818-415-1708
Mailing Address - Fax:
Practice Address - Street 1:9425 IRENE AVE
Practice Address - Street 2:
Practice Address - City:CALIFORNIA CITY
Practice Address - State:CA
Practice Address - Zip Code:93505-1216
Practice Address - Country:US
Practice Address - Phone:181-841-5170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80229225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist