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General NPI Number Information
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NPI Number | 1710577168
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Entity Type | Individual
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Provider Name | LATASHA CHRISTINE MOON CRANIAL PROSTHESIS
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Gender | Female
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Dates
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Enumeration Date | 01/20/2021
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Last Update Date | 01/20/2021
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Provider Practice Location Address
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Address Line | 1267 WILLIS ST # 200
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City | REDDING
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State | CA
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Zip | 96001-0400
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Country | US
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Telephone | 916-365-2013
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Fax |
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Provider Business Mailing Address
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Address Line | 9821 PARTINGTON CIR
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City | ELK GROVE
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State | CA
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Zip | 95757-6282
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Country | US
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Telephone | 216-798-4599
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State | CA
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