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General NPI Number Information
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NPI Number | 1508221573
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Entity Type | Individual
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Provider Name | DESIREE MORENO DAT, LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 12/17/2015
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Last Update Date | 05/22/2024
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Provider Practice Location Address
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Address Line | 1356 VISTA PL
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City | RATON
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State | NM
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Zip | 87740-2221
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Country | US
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Telephone | 715-554-2728
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Fax |
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Provider Business Mailing Address
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Address Line | 723 W JEFFERSON ST
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City | TRINIDAD
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State | CO
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Zip | 81082-3667
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Country | US
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Telephone | 719-557-0570
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 1454-39
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT.0001395
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License Number State | CO
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