Healthcare Provider Details

I. General information

NPI: 1174657100
Provider Name (Legal Business Name): MARICELA MORENO BACHELOR OF ARTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 3
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

2010 W JEFFERSON ST
BANNING CA
92220-4217
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-8320
  • Fax: 951-509-8322
Mailing address:
  • Phone: 562-587-7075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: