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General NPI Number Information
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NPI Number | 1093584815
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Entity Type | Individual
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Provider Name | DONNIE JAY MORENO I
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Gender | Male
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Dates
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Enumeration Date | 12/20/2023
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Last Update Date | 01/29/2024
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Provider Practice Location Address
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Address Line | 462 PRESCOTT ST
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City | PASADENA
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State | CA
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Zip | 91104-2858
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Country | US
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Telephone | 626-485-2635
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Fax |
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Provider Business Mailing Address
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Address Line | 221 FREMONT AVE
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City | SOUTH PASADENA
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State | CA
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Zip | 91030
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Country | US
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Telephone | 626-485-2635
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WW0000X
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Taxonomy Name | Wound Care Registered Nurse
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License Number | 8CB9E
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 225400000X
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Taxonomy Name | Rehabilitation Practitioner
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License Number | 1051707
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 1051707
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License Number State | CA
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