Provider Demographics
NPI:1962235846
Name:MORENO, ILIANA
Entity type:Individual
Prefix:
First Name:ILIANA
Middle Name:
Last Name: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 1:43520 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4089
Mailing Address - Country:US
Mailing Address - Phone:661-266-4783
Mailing Address - Fax:
Practice Address - Street 1:37344 WILD TREE ST
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7758
Practice Address - Country:US
Practice Address - Phone:818-421-0763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-263376OtherMEDI-CAL