Provider Demographics
NPI:1568281095
Name:BAUTISTA-MORENO, KARINA
Entity type:Individual
Prefix:
First Name:KARINA
Middle Name:
Last Name:BAUTISTA-MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 981
Mailing Address - Street 2:
Mailing Address - City:CEDAR GLEN
Mailing Address - State:CA
Mailing Address - Zip Code:92321-0981
Mailing Address - Country:US
Mailing Address - Phone:909-238-1406
Mailing Address - Fax:
Practice Address - Street 1:1738 N WATERMAN AVE STE 1&2
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5131
Practice Address - Country:US
Practice Address - Phone:909-693-3302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator