MEDICARE: MARIO LUIS MORENO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1265255830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO LUIS MORENO

Provider Business Mailing Address
First Line	:	131 NICHOLAS PKWY E
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-2802
Country	:	US
Telephone Number	:	239-440-7541
Fax Number	:

Provider Business Practice Location Address
First Line	:	114 DEL PRADO BLVD S STE 100
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-1724
Country	:	US
Telephone Number	:	239-471-2874
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2024
Last Update Date	:	11/04/2024

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Directions to “ MARIO LUIS MORENO ” Practice Location

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