Provider Demographics
NPI:1962178855
Name:REYNOSO, MOISES (CA CMT#67351)
Entity type:Individual
Prefix:
First Name:MOISES
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:M
Credentials:CA CMT#67351
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E GRAND AVE # G
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-2803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 E GRAND AVE # G
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-2803
Practice Address - Country:US
Practice Address - Phone:442-777-3255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67351225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist