Healthcare Provider Details

I. General information

NPI: 1932015500
Provider Name (Legal Business Name): MOSES JACOB BERRIOS-HEREDIA LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 ARDEN WAY STE 119
SACRAMENTO CA
95815-4027
US

IV. Provider business mailing address

164 LILY BAY CIR
SACRAMENTO CA
95834-7764
US

V. Phone/Fax

Practice location:
  • Phone: 408-489-7162
  • Fax:
Mailing address:
  • Phone: 408-489-7162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberVN276908
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberVN276908
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberVN276908
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN276908
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: