Healthcare Provider Details

I. General information

NPI: 1770581423
Provider Name (Legal Business Name): KATAYOUN MOINI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHY MOINI PA

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 E MARIPOSA AVE
EL SEGUNDO CA
90245-5027
US

IV. Provider business mailing address

2040 E MARIPOSA AVE
EL SEGUNDO CA
90245-5027
US

V. Phone/Fax

Practice location:
  • Phone: 213-266-5600
  • Fax: 213-477-2344
Mailing address:
  • Phone: 213-266-5600
  • Fax: 562-548-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number813546
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number813546
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA51495
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: