Provider Demographics
NPI:1215512579
Name:DE LA MORA, TATIANA
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:DE LA MORA
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 1:337 E 220TH ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3105
Mailing Address - Country:US
Mailing Address - Phone:310-251-1722
Mailing Address - Fax:
Practice Address - Street 1:3900 LOMALAND DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-2899
Practice Address - Country:US
Practice Address - Phone:619-849-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer