Healthcare Provider Details

I. General information

NPI: 1366332421
Provider Name (Legal Business Name): JOSEPH DANIEL MORENA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 SONOMA AVE
SANTA ROSA CA
95404-4713
US

IV. Provider business mailing address

1001 BELLEVUE AVE APT 2018
SANTA ROSA CA
95407-2704
US

V. Phone/Fax

Practice location:
  • Phone: 707-544-3295
  • Fax:
Mailing address:
  • Phone: 707-775-9093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: