Provider Demographics
NPI:1043595861
Name:MORENO, PETER IV (SOIDC)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:MORENO
Suffix:IV
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC BOX 20183
Mailing Address - Street 2:2D MARINE SPECIAL OPERATIONS BATTALION
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0183
Mailing Address - Country:US
Mailing Address - Phone:910-440-7704
Mailing Address - Fax:
Practice Address - Street 1:PSC BOX 20183
Practice Address - Street 2:2D MARINE SPECIAL OPERATIONS BATTALION
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0116
Practice Address - Country:US
Practice Address - Phone:910-440-7704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman