1275589905 NPI number — CHRISTOPHER AL MORENO M.D.

Table of content: CHRISTOPHER AL MORENO M.D. (NPI 1275589905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275589905 NPI number — CHRISTOPHER AL MORENO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO
Provider First Name:
CHRISTOPHER
Provider Middle Name:
AL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1275589905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
307 ST. JOHNS WAY
Provider Second Line Business Mailing Address:
SUITE 11
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-743-7612
Provider Business Mailing Address Fax Number:
208-746-4802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 ST. JOHNS WAY
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-7612
Provider Business Practice Location Address Fax Number:
208-746-4802
Provider Enumeration Date:
05/25/2006

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: 208600000X , with the licence number:  M5071 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208600000X , with the licence number: MD00024021 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000010002753 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: D0782 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8909565 . This is a "WA CRIME VICTIMS PROGRAM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1021856 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002599100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0096144 . This is a "WA LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 020006062 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 82040040083501A003 . This is a "TRICARE/TRI WEST" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com