Basic Information
| Provider Information | |||||||||
| NPI: | 1548609209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | FERNANDO | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 EAGLE ROCK AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | EAST HANOVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079363167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738879000 | ||||||||
| FaxNumber: | 9738873816 | ||||||||
| Practice Location | |||||||||
| Address1: | 6612-18 BERGENLINE AVE. | ||||||||
| Address2: | |||||||||
| City: | WEST NEW YORK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018545511 | ||||||||
| FaxNumber: | 2018545522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2013 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 036219 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 40QA01535200 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.