Healthcare Provider Details

I. General information

NPI: 1578012068
Provider Name (Legal Business Name): LESLIE MOYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3195 MILL ST
RENO NV
89502-2201
US

IV. Provider business mailing address

749 PUTNAM DR
RENO NV
89503-5906
US

V. Phone/Fax

Practice location:
  • Phone: 775-410-7832
  • Fax:
Mailing address:
  • Phone: 775-323-2627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0475
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: