1710957519 NPI number — JOE MORENO RDH

Table of content: JOE MORENO RDH (NPI 1710957519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710957519 NPI number — JOE MORENO RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO
Provider First Name:
JOE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RDH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710957519
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 MANSFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIMANTIC
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06226-2018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-450-7471
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 POMFRET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUTNAM
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06260-1833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-963-7917
Provider Business Practice Location Address Fax Number:
860-963-0015
Provider Enumeration Date:
01/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  006540 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)