Provider Demographics
NPI:1760220958
Name:MORENO DEL VALLE, GERARDO
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:MORENO DEL VALLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9076 MAC LN
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-2716
Mailing Address - Country:US
Mailing Address - Phone:619-708-4146
Mailing Address - Fax:
Practice Address - Street 1:UABC CAMPUS TIJUANA, UNIVERSIDAD 14418
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22390
Practice Address - Country:MX
Practice Address - Phone:664-979-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ1270070133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist