Provider Demographics
NPI:1104963602
Name:MORONE, EDWARD JACOBO (PT)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:JACOBO
Last Name:MORONE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:EDUARDO
Other - Middle Name:JACOBO
Other - Last Name:MORONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICPT,LICACUP
Mailing Address - Street 1:4971 LE CHALET BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-1418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1680 SE LYNGATE DR STE 203
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4300
Practice Address - Country:US
Practice Address - Phone:772-773-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT17740225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist