Provider Demographics
NPI:1487020681
Name:MORA, LUIS ROBERTO (RD)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:ROBERTO
Last Name:MORA
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10207 SAN ANSELMO AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-5624
Mailing Address - Country:US
Mailing Address - Phone:323-360-4050
Mailing Address - Fax:
Practice Address - Street 1:5807 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-5303
Practice Address - Country:US
Practice Address - Phone:323-233-2452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86003373133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered