Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | OTT.211550 | LA |
NPI | 1023552064 |
---|---|
Provider Name | Mr. Javier E Moreno |
First Address | Amite, LA 70422 |
Second Address | Amite, LA 70422 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2016 |
Last Update Date | 09/12/2016 |