Healthcare Provider Details

I. General information

NPI: 1467339663
Provider Name (Legal Business Name): MARIANA MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 HIGHWAY 98 BYP
COLUMBIA MS
39429-3702
US

IV. Provider business mailing address

42465 HIGHWAY 195
HALEYVILLE AL
35565-7052
US

V. Phone/Fax

Practice location:
  • Phone: 601-444-5050
  • Fax: 601-444-5072
Mailing address:
  • Phone: 256-350-1764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8056
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: