Provider Demographics
NPI:1669135117
Name:LOR, MOUANGCHEE LUCKY
Entity type:Individual
Prefix:
First Name:MOUANGCHEE
Middle Name:LUCKY
Last Name:LOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7620 GREENWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80221-3759
Mailing Address - Country:US
Mailing Address - Phone:719-322-1064
Mailing Address - Fax:
Practice Address - Street 1:7620 GREENWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80221-3759
Practice Address - Country:US
Practice Address - Phone:719-322-1064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOTA-2853224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant