MEDICARE: MARICELA MORENO BACHELOR OF ARTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1174657100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARICELA MORENO BACHELOR OF ARTS

Provider Business Mailing Address
First Line	:	2010 W JEFFERSON ST
Second Line	:
City	:	BANNING
State	:	CA
Zip	:	92220-4217
Country	:	US
Telephone Number	:	562-587-7075
Fax Number	:

Provider Business Practice Location Address
First Line	:	9890 COUNTY FARM RD STE 3
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92503-3678
Country	:	US
Telephone Number	:	951-509-8320
Fax Number	:	951-509-8322

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	08/31/2023

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