MEDICARE: SHELBY FACUNDO-MORENO

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	247200000X	Other Technician

General Provider Information

NPI Number	:	1497241202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY FACUNDO-MORENO

Provider Business Mailing Address
First Line	:	3605 E RAMON RD
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92264-1150
Country	:	US
Telephone Number	:	760-325-5630
Fax Number	:

Provider Business Practice Location Address
First Line	:	3605 E RAMON RD
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92264-1150
Country	:	US
Telephone Number	:	760-325-5630
Fax Number	:

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

Provider Enumeration Date	:	07/03/2018
Last Update Date	:	07/03/2018

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