Provider Demographics
NPI:1770002107
Name:MORENO MEDICAL CLINIC WEST
Entity type:Organization
Organization Name:MORENO MEDICAL CLINIC WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:F
Authorized Official - Last Name:MENA
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:210-994-6181
Mailing Address - Street 1:426 CASTROVILLE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-5169
Mailing Address - Country:US
Mailing Address - Phone:210-994-6181
Mailing Address - Fax:
Practice Address - Street 1:426 CASTROVILLE RD STE 4
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5169
Practice Address - Country:US
Practice Address - Phone:210-994-6181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty