1730985417 NPI number — MRS. ERICA VIRIDIANA MORENO LSW

Table of content: MRS. ERICA VIRIDIANA MORENO LSW (NPI 1730985417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730985417 NPI number — MRS. ERICA VIRIDIANA MORENO LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO
Provider First Name:
ERICA
Provider Middle Name:
VIRIDIANA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RODRIGUEZ
Provider Other First Name:
ERICA
Provider Other Middle Name:
VIRIDIANA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730985417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1108 HAINESVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROUND LAKE BEACH
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60073-2202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-971-5501
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
649 BARRON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAYSLAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60030-1343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-200-8520
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2025

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: 104100000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com