Healthcare Provider Details

I. General information

NPI: 1831954593
Provider Name (Legal Business Name): MARINA ELENA MORENO BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3772 TIBBETTS ST
RIVERSIDE CA
92506-2605
US

IV. Provider business mailing address

22495 KINROSS LN
MORENO VALLEY CA
92557-6807
US

V. Phone/Fax

Practice location:
  • Phone: 888-743-7526
  • Fax:
Mailing address:
  • Phone: 951-345-9168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95323883
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: