Healthcare Provider Details

I. General information

NPI: 1336492974
Provider Name (Legal Business Name): DEVADAS MOSES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 HULEN PL
RIVERSIDE CA
92507-2606
US

IV. Provider business mailing address

2880 HULEN PL
RIVERSIDE CA
92507-2606
US

V. Phone/Fax

Practice location:
  • Phone: 951-715-3448
  • Fax: 951-715-3449
Mailing address:
  • Phone: 951-715-3448
  • Fax: 951-715-3449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberA046492
License Number StateCA

VIII. Authorized Official

Name: MRS. DHARMASEELI E MOSES
Title or Position: CLINICAL SERVICES COORDINATOR
Credential:
Phone: 951-715-3448