Provider Demographics
NPI:1003548306
Name:LOPEZ, RUBEN
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:
Last Name:LOPEZ
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 1:120 N AVENUE B
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78839-3519
Mailing Address - Country:US
Mailing Address - Phone:701-730-3764
Mailing Address - Fax:
Practice Address - Street 1:120 N AVENUE B
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78839-3519
Practice Address - Country:US
Practice Address - Phone:701-730-3764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44667937343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)