Healthcare Provider Details

I. General information

NPI: 1982768628
Provider Name (Legal Business Name): MS. CONNIE J MORIATIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 MCCLINTIC STREET
GROESBECK TX
76642
US

IV. Provider business mailing address

PO BOX 401
GROESBECK TX
76642-0401
US

V. Phone/Fax

Practice location:
  • Phone: 254-729-5463
  • Fax: 254-549-1000
Mailing address:
  • Phone: 254-729-5463
  • Fax: 254-549-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: