Healthcare Provider Details

I. General information

NPI: 1508221573
Provider Name (Legal Business Name): DESIREE MORENO DAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1356 VISTA PL
RATON NM
87740-2221
US

IV. Provider business mailing address

723 W JEFFERSON ST
TRINIDAD CO
81082-3667
US

V. Phone/Fax

Practice location:
  • Phone: 715-554-2728
  • Fax:
Mailing address:
  • Phone: 719-557-0570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1454-39
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0001395
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: