Provider Demographics
NPI:1285171827
Name:MORENO, CICELY (MD)
Entity type:Individual
Prefix:
First Name:CICELY
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 LONGMEADOW VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-7809
Mailing Address - Country:US
Mailing Address - Phone:269-684-6000
Mailing Address - Fax:
Practice Address - Street 1:4 LONGMEADOW VILLAGE DR
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-7809
Practice Address - Country:US
Practice Address - Phone:269-684-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01083223A207Q00000X
MI4301509637207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine