Provider Demographics
NPI:1801035308
Name:MORA, CHARLES H (LMT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:H
Last Name:MORA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 N ATLANTIC AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-5111
Mailing Address - Country:US
Mailing Address - Phone:321-917-3329
Mailing Address - Fax:
Practice Address - Street 1:5505 N ATLANTIC AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5111
Practice Address - Country:US
Practice Address - Phone:321-917-3329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-07
Last Update Date:2009-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA7779174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA7779OtherSTATE LICENSE NUMBER