Healthcare Provider Details

I. General information

NPI: 1104735422
Provider Name (Legal Business Name): CHRISTIAN DAVID LE MOSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 SOQUEL AVE
SANTA CRUZ CA
95062-2301
US

IV. Provider business mailing address

29 KINGFISHER DR
WATSONVILLE CA
95076-6627
US

V. Phone/Fax

Practice location:
  • Phone: 831-426-7322
  • Fax:
Mailing address:
  • Phone: 831-426-7322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: