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General NPI Number Information
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NPI Number | 1649710971
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Entity Type | Organization
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Legal Business Name | TIMOTHY R. MORENO, MD, INC
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Dates
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Enumeration Date | 03/06/2017
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Last Update Date | 03/06/2017
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Provider Practice Location Address
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Address Line | 105 S FOREST RD
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City | SONORA
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State | CA
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Zip | 95370-4895
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Country | US
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Telephone | 209-532-1255
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Fax | 209-532-8436
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Provider Business Mailing Address
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Address Line | 105 S FOREST RD
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City | SONORA
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State | CA
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Zip | 95370-4895
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Country | US
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Telephone | 209-532-1255
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Fax | 209-532-8436
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Authorized Official
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Title or Position | PRESIDENT
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Name | TIMOTHY R MORENO
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Credential | M.D.
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Telephone | 209-840-2575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | A45369
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License Number State | CA
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