Healthcare Provider Details

I. General information

NPI: 1578065934
Provider Name (Legal Business Name): SHAE NICOLE MORGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12891 INDIANA AVE UNIT 41
RIVERSIDE CA
92503-4679
US

IV. Provider business mailing address

12891 INDIANA AVE UNIT 41
RIVERSIDE CA
92503-4679
US

V. Phone/Fax

Practice location:
  • Phone: 714-319-0985
  • Fax:
Mailing address:
  • Phone: 714-319-0985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberBOC325316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: