Healthcare Provider Details

I. General information

NPI: 1639629181
Provider Name (Legal Business Name): MORA HANNA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2016
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 S MILLIKEN AVE STE E
ONTARIO CA
91761-8112
US

IV. Provider business mailing address

7331 SHELBY PL APT 53
RANCHO CUCAMONGA CA
91739-5907
US

V. Phone/Fax

Practice location:
  • Phone: 909-815-4328
  • Fax:
Mailing address:
  • Phone: 909-815-4328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number40963
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40963
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number40963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: