Provider Demographics
NPI:1699291468
Name:JERRAR, MOE (RCFE)
Entity type:Individual
Prefix:
First Name:MOE
Middle Name:
Last Name:JERRAR
Suffix:
Gender:M
Credentials:RCFE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N CAROUSEL PL
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-3206
Mailing Address - Country:US
Mailing Address - Phone:714-809-4444
Mailing Address - Fax:714-333-4412
Practice Address - Street 1:525 N CAROUSEL PL
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-3206
Practice Address - Country:US
Practice Address - Phone:714-809-4444
Practice Address - Fax:714-333-4412
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
CA6039504740374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No171W00000XOther Service ProvidersContractor