Healthcare Provider Details

I. General information

NPI: 1952951857
Provider Name (Legal Business Name): DUSTIN MOURA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

498 PALM SPRINGS DR STE 345
ALTAMONTE SPRINGS FL
32701-7806
US

IV. Provider business mailing address

498 PALM SPRINGS DR STE 345
ALTAMONTE SPRINGS FL
32701-7806
US

V. Phone/Fax

Practice location:
  • Phone: 407-388-8866
  • Fax:
Mailing address:
  • Phone: 407-388-8866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: