Provider Demographics
NPI:1033668074
Name:ROBERT LOPEZ EXTENDER PLUS, LLC
Entity Type:Organization
Organization Name:ROBERT LOPEZ EXTENDER PLUS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:754-800-7730
Mailing Address - Street 1:4451 NE 30TH TER
Mailing Address - Street 2:
Mailing Address - City:LIGHTHOUSE POINT
Mailing Address - State:FL
Mailing Address - Zip Code:33064-7229
Mailing Address - Country:US
Mailing Address - Phone:352-585-7527
Mailing Address - Fax:754-800-7730
Practice Address - Street 1:4451 NE 30TH TER
Practice Address - Street 2:
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-7229
Practice Address - Country:US
Practice Address - Phone:352-585-7527
Practice Address - Fax:754-800-7730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015779500Medicaid
FL015779500Medicaid