MEDICARE: MR. CHARLES H MORA LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA7779	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA7779	OTHER	FL	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1801035308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES H MORA LMT

Provider Business Mailing Address
First Line	:	5505 N ATLANTIC AVE
Second Line	:	SUITE 106
City	:	COCOA BEACH
State	:	FL
Zip	:	32931-5111
Country	:	US
Telephone Number	:	321-917-3329
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 N ATLANTIC AVE
Second Line	:	SUITE 106
City	:	COCOA BEACH
State	:	FL
Zip	:	32931-5111
Country	:	US
Telephone Number	:	321-917-3329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2009
Last Update Date	:	02/07/2009

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