1316067523 NPI number — MISS MARLA MARI MORENO B.S STA

Table of content: MISS MARLA MARI MORENO B.S STA (NPI 1316067523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316067523 NPI number — MISS MARLA MARI MORENO B.S STA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO
Provider First Name:
MARLA
Provider Middle Name:
MARI
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
B.S STA
Provider Gender Code:
F

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:
1316067523
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 E WALNUT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78501-9471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-605-0597
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18360 FM 493
Provider Second Line Business Practice Location Address:
LA BLANCA MEDICAL CTR. STE. # 3
Provider Business Practice Location Address City Name:
LA BLANCA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-262-1192
Provider Business Practice Location Address Fax Number:
956-262-9226
Provider Enumeration Date:
03/30/2007

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: 2355S0801X , with the licence number:  33099 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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