Provider Demographics
NPI:1376897611
Name:MORENA, RYAN TYLER
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TYLER
Last Name:MORENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 N ATLANTIC BLVD
Mailing Address - Street 2:UNIT C
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1332
Mailing Address - Country:US
Mailing Address - Phone:626-253-9320
Mailing Address - Fax:
Practice Address - Street 1:1126 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1551
Practice Address - Country:US
Practice Address - Phone:626-253-9320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator