Provider Demographics
NPI:1396117628
Name:FERNANDO MORENO PHYSICAL THERAPY
Entity type:Organization
Organization Name:FERNANDO MORENO PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPT
Authorized Official - Phone:917-306-0725
Mailing Address - Street 1:6050 KENNEDY BLVD E
Mailing Address - Street 2:APT 2G
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3901
Mailing Address - Country:US
Mailing Address - Phone:917-306-0725
Mailing Address - Fax:
Practice Address - Street 1:6050 KENNEDY BLVD E
Practice Address - Street 2:APT 2G
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-3901
Practice Address - Country:US
Practice Address - Phone:917-306-0725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036219261QP2000X
NJ40QA015352001261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy