Provider Demographics
NPI:1629504642
Name:CARISSA MORA-RODRIGUEZ
Entity Type:Organization
Organization Name:CARISSA MORA-RODRIGUEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORA-RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-556-8064
Mailing Address - Street 1:415 E WOODLAKE LN
Mailing Address - Street 2:#152
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1990
Mailing Address - Country:US
Mailing Address - Phone:801-556-8064
Mailing Address - Fax:
Practice Address - Street 1:415 E WOODLAKE LN
Practice Address - Street 2:#152
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1990
Practice Address - Country:US
Practice Address - Phone:801-556-8064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization