Provider Demographics
NPI:1770610065
Name:MORENO, RAFAEL (DC)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 JACKSON LN
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7222
Mailing Address - Country:US
Mailing Address - Phone:512-392-5750
Mailing Address - Fax:512-392-5320
Practice Address - Street 1:132 JACKSON LN
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7222
Practice Address - Country:US
Practice Address - Phone:512-392-5750
Practice Address - Fax:512-392-5320
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9756111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S0560OtherBLUE CROSS BLUE SHIELD
TX8S0560OtherBLUE CROSS BLUE SHIELD