Provider Demographics
NPI:1649586264
Name:MOORE, SANJANA
Entity Type:Individual
Prefix:
First Name:SANJANA
Middle Name:
Last Name:MOORE
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 1:1001 E COOLEY DR
Mailing Address - Street 2:STE. 101
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3941
Mailing Address - Country:US
Mailing Address - Phone:909-783-1111
Mailing Address - Fax:
Practice Address - Street 1:1001 E COOLEY DR
Practice Address - Street 2:STE. 101
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3941
Practice Address - Country:US
Practice Address - Phone:909-783-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4267225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics