Basic Information
| Provider Information | |||||||||
| NPI: | 1821043654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | CECILIA | ||||||||
| MiddleName: | CHAVEZ | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7720 N FRESNO ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937202407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594382300 | ||||||||
| FaxNumber: | 5594381531 | ||||||||
| Practice Location | |||||||||
| Address1: | 7720 N FRESNO ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937202407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594382300 | ||||||||
| FaxNumber: | 5594381531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 10/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A68973 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00A689730 | 05 | AL | MEDICAID |