Provider Demographics
NPI:1346097177
Name:MORENO, AIDA AMANDA (RDN)
Entity type:Individual
Prefix:
First Name:AIDA
Middle Name:AMANDA
Last Name:MORENO
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 STATION WAY
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3359
Mailing Address - Country:US
Mailing Address - Phone:805-473-6201
Mailing Address - Fax:
Practice Address - Street 1:260 STATION WAY
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3359
Practice Address - Country:US
Practice Address - Phone:805-473-6201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86297023133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered