Provider Demographics
NPI:1669927802
Name:MORENO, MARITZA (RD, LDN)
Entity type:Individual
Prefix:
First Name:MARITZA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7239
Mailing Address - Country:US
Mailing Address - Phone:224-587-7624
Mailing Address - Fax:
Practice Address - Street 1:1108 SOUTH ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7239
Practice Address - Country:US
Practice Address - Phone:224-587-7624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006366133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered