Healthcare Provider Details

I. General information

NPI: 1316779077
Provider Name (Legal Business Name): ANGELA MORENO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 STOCKDALE HWY
BAKERSFIELD CA
93309-2656
US

IV. Provider business mailing address

5025 TIERRA ABIERTA DR
BAKERSFIELD CA
93307-8341
US

V. Phone/Fax

Practice location:
  • Phone: 661-868-6840
  • Fax:
Mailing address:
  • Phone: 661-308-8250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name: ANGELA A MORENO
Title or Position: VOLUNTEER
Credential:
Phone: 661-308-8250