Healthcare Provider Details

I. General information

NPI: 1457944621
Provider Name (Legal Business Name): BRIEANNA MARIE MORALES RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 02/18/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 5TH ST
CLIFTON AZ
85533
US

IV. Provider business mailing address

PO BOX 936
CLIFTON AZ
85533-0936
US

V. Phone/Fax

Practice location:
  • Phone: 928-865-2601
  • Fax: 928-865-1929
Mailing address:
  • Phone: 928-865-2601
  • Fax: 928-865-1929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86048227
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: