Basic Information
| Provider Information | |||||||||
| NPI: | 1487020681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORA | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | ROBERTO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10207 SAN ANSELMO AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH GATE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902805624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233604050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5807 AVALON BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900115303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232332452 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2015 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86003373 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.