Healthcare Provider Details

I. General information

NPI: 1760763270
Provider Name (Legal Business Name): CARLOS X MORENO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 VALLEY VIEW DR
MOLINE IL
61265-6152
US

IV. Provider business mailing address

2300 53RD AVE STE 100
BETTENDORF IA
52722-7565
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-3621
  • Fax:
Mailing address:
  • Phone: 635-322-0971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License NumberD164283
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number209008943
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041353932
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209008943
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: