Healthcare Provider Details

I. General information

NPI: 1396506226
Provider Name (Legal Business Name): LUIS MEJIA MORALES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARTHA JEFFERSON DR
CHARLOTTESVILLE VA
22911-4668
US

IV. Provider business mailing address

2460 WINTHROP DR
CHARLOTTESVILLE VA
22911-3578
US

V. Phone/Fax

Practice location:
  • Phone: 434-654-7000
  • Fax:
Mailing address:
  • Phone: 336-596-0640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001265998
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: