Healthcare Provider Details

I. General information

NPI: 1114211992
Provider Name (Legal Business Name): ANGEL D MORA CRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12420 SW 192ND TER
MIAMI FL
33177-3800
US

IV. Provider business mailing address

12420 SW 192ND TER
MIAMI FL
33177-3800
US

V. Phone/Fax

Practice location:
  • Phone: 786-389-0801
  • Fax: 786-429-1701
Mailing address:
  • Phone: 786-389-0801
  • Fax: 786-429-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberCRT 69470
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: