Healthcare Provider Details

I. General information

NPI: 1295007771
Provider Name (Legal Business Name): MR. MANUEL M MORENO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2933 N EL NIDO DR. EL NIDO CAMPUS
ALTADENA CA
91104
US

IV. Provider business mailing address

2933 N EL NIDO DR. EL NIDO CAMPUS
ALTADENA CA
91104
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 626-395-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: