MEDICARE: MR. JESUS 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	3747P1801X	Personal Care Attendant		AZ

General Provider Information

NPI Number	:	1750506184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESUS MORENO

Provider Business Mailing Address
First Line	:	1522 E.SOUTHERN AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85040-3543
Country	:	US
Telephone Number	:	602-243-1773
Fax Number	:

Provider Business Practice Location Address
First Line	:	7534 N. 46TH CIR
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85301-1676
Country	:	US
Telephone Number	:	623-847-5821
Fax Number	:

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

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	07/26/2007

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