Provider Demographics
NPI:1184013864
Name:MORENO, PRISCILLA
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9050 NEWBY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-4408
Mailing Address - Country:US
Mailing Address - Phone:626-372-4180
Mailing Address - Fax:
Practice Address - Street 1:9050 NEWBY AVE
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-4408
Practice Address - Country:US
Practice Address - Phone:626-372-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-17
Last Update Date:2015-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9665225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant