Provider Demographics
NPI:1780405423
Name:MORENO, GISELLE (LAC)
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 28TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-4504
Mailing Address - Country:US
Mailing Address - Phone:510-305-7296
Mailing Address - Fax:
Practice Address - Street 1:938 28TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-4504
Practice Address - Country:US
Practice Address - Phone:510-305-7296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC19939171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist