Healthcare Provider Details

I. General information

NPI: 1326910746
Provider Name (Legal Business Name): ANTHONY MORA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2025
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5951 JEFFERSON ST NE STE C
ALBUQUERQUE NM
87109-3450
US

IV. Provider business mailing address

5951 JEFFERSON ST NE STE C
ALBUQUERQUE NM
87109-3450
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4900
  • Fax: 505-933-6373
Mailing address:
  • Phone: 505-247-4900
  • Fax: 505-933-6373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA3375
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: