Provider Demographics
NPI:1992548093
Name:MORENO, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:MORENO
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 1:175 NATE WHIPPLE HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-1423
Mailing Address - Country:US
Mailing Address - Phone:401-999-7325
Mailing Address - Fax:401-400-5876
Practice Address - Street 1:175 NATE WHIPPLE HWY STE 201
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-1423
Practice Address - Country:US
Practice Address - Phone:401-999-7325
Practice Address - Fax:401-400-5876
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT00819-G225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist