Healthcare Provider Details

I. General information

NPI: 1568989176
Provider Name (Legal Business Name): ANGEL MOYEDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 ORANGE ST
RIVERSIDE CA
92501-3613
US

IV. Provider business mailing address

4000 ORANGE ST
RIVERSIDE CA
92501-3613
US

V. Phone/Fax

Practice location:
  • Phone: 760-617-6680
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: