Healthcare Provider Details

I. General information

NPI: 1093584815
Provider Name (Legal Business Name): DONNIE JAY MORENO I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHN GREENEWALD JR. FIOA/PA FOIA/PA

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 PRESCOTT ST
PASADENA CA
91104-2858
US

IV. Provider business mailing address

221 FREMONT AVE
SOUTH PASADENA CA
91030
US

V. Phone/Fax

Practice location:
  • Phone: 626-485-2635
  • Fax:
Mailing address:
  • Phone: 626-485-2635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number8CB9E
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number1051707
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number1051707
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: