Provider Demographics
NPI:1841643780
Name:MORA, VIDAL LUIS (LAT, ATC)
Entity type:Individual
Prefix:
First Name:VIDAL
Middle Name:LUIS
Last Name:MORA
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7140 WELSH DR
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-4870
Mailing Address - Country:US
Mailing Address - Phone:636-288-1928
Mailing Address - Fax:
Practice Address - Street 1:7140 WELSH DR
Practice Address - Street 2:
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-4870
Practice Address - Country:US
Practice Address - Phone:636-288-1928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150233522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer