Basic Information
| Provider Information | |||||||||
| NPI: | 1962954024 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRED JEFFERSON MORENO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FRED JEFFERSON M AFTERCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 12981 PERRIS BLVD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925534102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107631660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 152 W WALNUT ST | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902483141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107631660 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2016 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SEWELL | ||||||||
| AuthorizedOfficialFirstName: | DARRYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CTO/PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3109290738 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
No ID Information.