1093584815 NPI number — DONNIE JAY MORENO I

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093584815 NPI number — DONNIE JAY MORENO I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO
Provider First Name:
DONNIE
Provider Middle Name:
JAY
Provider Name Prefix Text:
Provider Name Suffix Text:
I
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREENEWALD
Provider Other First Name:
JOHN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
FIOA/PA FOIA/PA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1093584815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 FREMONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-485-2635
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
462 PRESCOTT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91104-2858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-485-2635
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WW0000X , with the licence number:  8CB9E , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225400000X , with the licence number: 1051707 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081S0010X , with the licence number: 1051707 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1051707 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8CB9E . This is a "BASIC LIFE SUPPORT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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