Healthcare Provider Details

I. General information

NPI: 1740095975
Provider Name (Legal Business Name): MARLO MORENO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 S CONGRESS AVE STE 301
AUSTIN TX
78745-4483
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 512-270-2060
  • Fax:
Mailing address:
  • Phone: 726-202-3039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1405079
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: