Healthcare Provider Details

I. General information

NPI: 1952813420
Provider Name (Legal Business Name): SHANAYA FREDERICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14929 SPINNAKER LANE
MORENO VALLEY CA
92553
US

IV. Provider business mailing address

14929 SPINNAKER LN
MORENO VALLEY CA
92553-9410
US

V. Phone/Fax

Practice location:
  • Phone: 951-421-9044
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: