=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891344776
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAGDALENO MORENO II
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2019
-----------------------------------------------------
Last Update Date | 09/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1393 E ALTON GLOOR BLVD STE 8
-----------------------------------------------------
City | BROWNSVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78526-3401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-545-0009
-----------------------------------------------------
Fax | 956-545-0009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9565 LOS OLMOS
-----------------------------------------------------
City | LOS FRESNOS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78566-4589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-742-9670
-----------------------------------------------------
Fax | 956-545-0009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374700000X
-----------------------------------------------------
Taxonomy Name | Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------