Healthcare Provider Details

I. General information

NPI: 1366150955
Provider Name (Legal Business Name): JOSE ANTONIO MOYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 E 9TH ST SPC 25
SAN BERNARDINO CA
92410-4053
US

IV. Provider business mailing address

760 E 9TH ST SPC 25
SAN BERNARDINO CA
92410-4053
US

V. Phone/Fax

Practice location:
  • Phone: 909-521-4268
  • Fax:
Mailing address:
  • Phone: 909-521-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberE170039
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: