Healthcare Provider Details

I. General information

NPI: 1235649443
Provider Name (Legal Business Name): MRS. PATRICIA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 INLAND EMPIRE BLVD
ONTARIO CA
91764-4898
US

IV. Provider business mailing address

2940 INLAND EMPIRE BLVD
ONTARIO CA
91764-4898
US

V. Phone/Fax

Practice location:
  • Phone: 909-458-1350
  • Fax: 909-931-7551
Mailing address:
  • Phone: 909-458-1350
  • Fax: 909-931-7551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW115141
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: