Healthcare Provider Details

I. General information

NPI: 1558298547
Provider Name (Legal Business Name): DIANE CARROL MOSES SUDRC 2
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11646 ENCANTO LN
COLTON CA
92324-9218
US

IV. Provider business mailing address

10740 JASPER AVE
REDLANDS CA
92374-7680
US

V. Phone/Fax

Practice location:
  • Phone: 909-747-8962
  • Fax:
Mailing address:
  • Phone: 909-747-8962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: