Provider Demographics
NPI:1194979310
Name:MORENO, IVONNE (OTS)
Entity type:Individual
Prefix:MISS
First Name:IVONNE
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:OTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W. VICTORIA ST.
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248
Mailing Address - Country:US
Mailing Address - Phone:310-715-2020
Mailing Address - Fax:
Practice Address - Street 1:130 W. VICTORIA ST.
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248
Practice Address - Country:US
Practice Address - Phone:310-715-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program