Healthcare Provider Details

I. General information

NPI: 1215566757
Provider Name (Legal Business Name): EZEKIEL MORENO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 BENTWOOD DR
LANSING MI
48917-2035
US

IV. Provider business mailing address

1412 BENTWOOD DR
LANSING MI
48917-2035
US

V. Phone/Fax

Practice location:
  • Phone: 517-272-1478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberSC0000000913456
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401018236
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: