Provider Demographics
NPI:1336492974
Name:DEVADAS MOSES
Entity Type:Organization
Organization Name:DEVADAS MOSES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SERVICES COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DHARMASEELI
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-715-3448
Mailing Address - Street 1:2880 HULEN PL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2606
Mailing Address - Country:US
Mailing Address - Phone:951-715-3448
Mailing Address - Fax:951-715-3449
Practice Address - Street 1:2880 HULEN PL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2606
Practice Address - Country:US
Practice Address - Phone:951-715-3448
Practice Address - Fax:951-715-3449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA046492261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A464920Medicaid
CA00A464920Medicaid