Provider Demographics
NPI:1154207421
Name:MOCINOS VERGARA, KENIA ANDREA (PT)
Entity type:Individual
Prefix:
First Name:KENIA
Middle Name:ANDREA
Last Name:MOCINOS VERGARA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 GRAMERCY PL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-2208
Mailing Address - Country:US
Mailing Address - Phone:951-403-0022
Mailing Address - Fax:
Practice Address - Street 1:9900 INDIANA AVE STE 8
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5498
Practice Address - Country:US
Practice Address - Phone:951-376-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA308562225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist