Provider Demographics
NPI:1598237695
Name:MORA, NICETAS GAGAN
Entity Type:Individual
Prefix:MRS
First Name:NICETAS
Middle Name:GAGAN
Last Name:MORA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5275 87TH TER N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-5137
Mailing Address - Country:US
Mailing Address - Phone:727-504-9455
Mailing Address - Fax:727-754-7670
Practice Address - Street 1:9670 134TH ST
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776-1447
Practice Address - Country:US
Practice Address - Phone:727-596-3266
Practice Address - Fax:727-754-7670
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8295310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility