Provider Demographics
NPI:1770357642
Name:MORENO, EZEQUIEL DANIEL (LMT, CMMP)
Entity type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:DANIEL
Last Name:MORENO
Suffix:
Gender:M
Credentials:LMT, CMMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7832 SILVERTREE TRL APT 203
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-9010
Mailing Address - Country:US
Mailing Address - Phone:321-444-8609
Mailing Address - Fax:
Practice Address - Street 1:7832 SILVERTREE TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-9010
Practice Address - Country:US
Practice Address - Phone:321-444-8609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA98212225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist