Healthcare Provider Details

I. General information

NPI: 1114862679
Provider Name (Legal Business Name): ANGELICA L MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1774 ZONAL AVE BLDG B
LOS ANGELES CA
90033-1064
US

IV. Provider business mailing address

1774 ZONAL AVE BLDG B
LOS ANGELES CA
90033-1064
US

V. Phone/Fax

Practice location:
  • Phone: 310-221-6336
  • Fax:
Mailing address:
  • Phone: 310-221-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW128574
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: