Provider Demographics
NPI:1487074852
Name:MORENO, DICKIE
Entity type:Individual
Prefix:
First Name:DICKIE
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:S
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2017 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-1001
Mailing Address - Country:US
Mailing Address - Phone:562-434-4455
Mailing Address - Fax:562-433-6428
Practice Address - Street 1:2017 E 4TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-1001
Practice Address - Country:US
Practice Address - Phone:562-434-4455
Practice Address - Fax:562-433-6428
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner