Healthcare Provider Details

I. General information

NPI: 1154984706
Provider Name (Legal Business Name): ANTONIO MORENO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 N WATERMAN AVE
SAN BERNARDINO CA
92404-4836
US

IV. Provider business mailing address

25590 PROSPECT AVE APT 25H
LOMA LINDA CA
92354-3149
US

V. Phone/Fax

Practice location:
  • Phone: 909-883-8711
  • Fax:
Mailing address:
  • Phone: 323-440-1388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001104
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: