Healthcare Provider Details

I. General information

NPI: 1861756124
Provider Name (Legal Business Name): MR. MOSES IP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2012
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2129 DENA DR
CONCORD CA
94519-2222
US

IV. Provider business mailing address

440 N BARRANCA AVE # 4325
COVINA CA
91723-1722
US

V. Phone/Fax

Practice location:
  • Phone: 510-626-8012
  • Fax:
Mailing address:
  • Phone: 510-626-8012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: