Provider Demographics
NPI:1962954024
Name:FRED JEFFERSON MORENO
Entity type:Organization
Organization Name:FRED JEFFERSON MORENO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CTO/PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:SEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-929-0738
Mailing Address - Street 1:12981 PERRIS BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-4102
Mailing Address - Country:US
Mailing Address - Phone:310-763-1660
Mailing Address - Fax:
Practice Address - Street 1:152 W WALNUT ST
Practice Address - Street 2:SUITE 150
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-3141
Practice Address - Country:US
Practice Address - Phone:310-763-1660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management