Healthcare Provider Details

I. General information

NPI: 1083173405
Provider Name (Legal Business Name): NOEL ANTONIO MORA RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 SW 75TH AVE
MIAMI FL
33155-2805
US

IV. Provider business mailing address

2500 SW 75TH AVE
MIAMI FL
33155-2805
US

V. Phone/Fax

Practice location:
  • Phone: 305-264-5252
  • Fax:
Mailing address:
  • Phone: 305-264-5252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCBHCM102175-P
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTRN42496
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: