Provider Demographics
NPI:1528373131
Name:HILARIO, EDMON JONH MORENO
Entity type:Individual
Prefix:
First Name:EDMON JONH
Middle Name:MORENO
Last Name:HILARIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MITCHELL STREET
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343
Mailing Address - Country:US
Mailing Address - Phone:731-784-5183
Mailing Address - Fax:731-784-2105
Practice Address - Street 1:2400 MITCHELL STREET
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343
Practice Address - Country:US
Practice Address - Phone:731-784-5183
Practice Address - Fax:731-784-2105
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4301225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist