Basic Information
Provider Information | |||||||||
NPI: | 1114292786 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MORENO-CABRERA | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 203 S ROLLIE AVE | ||||||||
Address2: | BILLING DEPT - CREDENTIALIST | ||||||||
City: | FORT LUPTON | ||||||||
State: | CO | ||||||||
PostalCode: | 806211508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032864560 | ||||||||
FaxNumber: | 3032864589 | ||||||||
Practice Location | |||||||||
Address1: | 6255 QUEBEC PKWY | ||||||||
Address2: |   | ||||||||
City: | COMMERCE CITY | ||||||||
State: | CO | ||||||||
PostalCode: | 800224812 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032866755 | ||||||||
FaxNumber: | 3032864970 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2012 | ||||||||
LastUpdateDate: | 03/17/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 122300000X | DD3845 | NM | N |   | Dental Providers | Dentist |   | 122300000X | DEN.00202526 | CO | Y |   | Dental Providers | Dentist |   |
ID Information
ID | Type | State | Issuer | Description | 87780054 | 05 | CO |   | MEDICAID |