Provider Demographics
NPI:1790375020
Name:MORENO, SANDRA L (RD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:MORENO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20233
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97307-0233
Mailing Address - Country:US
Mailing Address - Phone:541-223-2355
Mailing Address - Fax:
Practice Address - Street 1:1201 COURT ST NE STE 310A
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4182
Practice Address - Country:US
Practice Address - Phone:503-395-8890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10181188133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty