Provider Demographics
NPI:1275030538
Name:MORALES, IANCARLO (ATC)
Entity type:Individual
Prefix:
First Name:IANCARLO
Middle Name:
Last Name:MORALES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 BONTA AVE
Mailing Address - Street 2:
Mailing Address - City:GUSTINE
Mailing Address - State:CA
Mailing Address - Zip Code:95322-1723
Mailing Address - Country:US
Mailing Address - Phone:209-829-8071
Mailing Address - Fax:
Practice Address - Street 1:2222 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-1240
Practice Address - Country:US
Practice Address - Phone:209-829-8071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer