Healthcare Provider Details

I. General information

NPI: 1821371667
Provider Name (Legal Business Name): GRAZIELLA G MORA B.S., ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NW PEACOCK BLVD SUITE 103-104
PORT ST LUCIE FL
34986-2366
US

IV. Provider business mailing address

10520 SW WATERWAY LN
PORT ST LUCIE FL
34987-1913
US

V. Phone/Fax

Practice location:
  • Phone: 772-646-4899
  • Fax: 772-646-4197
Mailing address:
  • Phone: 407-489-5614
  • Fax: 407-992-8663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 3186
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: