Healthcare Provider Details

I. General information

NPI: 1669533774
Provider Name (Legal Business Name): CLINICA MEDICA DE LA MORA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 GATEWAY CENTER WAY STE 202
SAN DIEGO CA
92102-4545
US

IV. Provider business mailing address

995 GATEWAY CENTER WAY STE 202
SAN DIEGO CA
92102-4545
US

V. Phone/Fax

Practice location:
  • Phone: 619-264-3107
  • Fax: 619-264-6927
Mailing address:
  • Phone: 619-264-3107
  • Fax: 619-264-6927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA507691
License Number StateCA

VIII. Authorized Official

Name: FERNANDO BECERRA
Title or Position: OFFICE MANAGER
Credential:
Phone: 619-264-3107