Healthcare Provider Details

I. General information

NPI: 1720672207
Provider Name (Legal Business Name): VICTOR ALFONSO MORON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 E SEQUOIA AVE
TULARE CA
93274-4508
US

IV. Provider business mailing address

648 S INDIANA ST
PORTERVILLE CA
93257-7821
US

V. Phone/Fax

Practice location:
  • Phone: 559-556-0030
  • Fax:
Mailing address:
  • Phone: 559-339-8238
  • 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: