1154776763 NPI number — MRS. CHRISTINA ANN MORENO RADT-I R1203630615

Table of content: MRS. CHRISTINA ANN MORENO RADT-I R1203630615 (NPI 1154776763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154776763 NPI number — MRS. CHRISTINA ANN MORENO RADT-I R1203630615

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO
Provider First Name:
CHRISTINA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RADT-I R1203630615
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154776763
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4200 ROCKLIN ROAD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
SACARMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-624-4428
Provider Business Mailing Address Fax Number:
916-672-6289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 ROCKLIN RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
ROCKLIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95677-2860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-624-4428
Provider Business Practice Location Address Fax Number:
916-672-6289
Provider Enumeration Date:
05/02/2016

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: 101YA0400X , with the licence number:  RADT-I R1203630615 , 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)





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