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General NPI Number Information
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NPI Number | 1578984712
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Entity Type | Individual
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Provider Name | LUPANA REGINA MORALES ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 12/13/2013
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 35 CIRCLE DR
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City | EDWARDSVILLE
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State | IL
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Zip | 62026-2210
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Country | US
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Telephone | 618-650-2160
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Fax |
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Provider Business Mailing Address
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Address Line | BOX 1129, VC 2210
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City | EDWARDSVILLE
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State | IL
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Zip | 62026-0001
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Country | US
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Telephone | 618-650-2169
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 096.005602
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License Number State | IL
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