Provider Demographics
NPI:1932573516
Name:MORA, MERCEDES (OTA)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:MORA
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 W 69TH PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-5109
Mailing Address - Country:US
Mailing Address - Phone:786-379-1730
Mailing Address - Fax:
Practice Address - Street 1:1132 W 69TH PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-5109
Practice Address - Country:US
Practice Address - Phone:786-379-1730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14919172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker