Provider Demographics
NPI:1942193180
Name:MOORE, PRENISHA MOORE ANGELIC
Entity type:Individual
Prefix:
First Name:PRENISHA MOORE
Middle Name:ANGELIC
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5222 PENDLETON AVE APT 14
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-8537
Mailing Address - Country:US
Mailing Address - Phone:323-861-4158
Mailing Address - Fax:
Practice Address - Street 1:5222 PENDLETON AVE APT 14
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-8537
Practice Address - Country:US
Practice Address - Phone:323-861-4158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier