Provider Demographics
NPI:1215557103
Name:MORA MUJICA, VIRGINIA (SA-C, IMG)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:MORA MUJICA
Suffix:
Gender:F
Credentials:SA-C, IMG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5963 CHURCHILL SQUARE WAY
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:FL
Mailing Address - Zip Code:34736-3128
Mailing Address - Country:US
Mailing Address - Phone:407-773-4009
Mailing Address - Fax:
Practice Address - Street 1:5963 CHURCHILL SQUARE WAY
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-3128
Practice Address - Country:US
Practice Address - Phone:407-773-4009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20210246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant