Healthcare Provider Details

I. General information

NPI: 1639616220
Provider Name (Legal Business Name): MAXIMO MORENO III CO 60653500
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5007 CLAREMONT WAY
EVERETT WA
98203-3321
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 425-609-5504
  • Fax: 425-609-5506
Mailing address:
  • Phone: 206-764-0502
  • Fax: 206-764-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1174784185
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: