Provider Demographics
NPI:1083300164
Name:LOPES, LUIZ GUSTAVO D
Entity Type:Individual
Prefix:
First Name:LUIZ GUSTAVO
Middle Name:D
Last Name:LOPES
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 1:19605 RIVER RD UNIT 100
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-2261
Mailing Address - Country:US
Mailing Address - Phone:503-791-4399
Mailing Address - Fax:
Practice Address - Street 1:19605 RIVER RD UNIT 100
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2261
Practice Address - Country:US
Practice Address - Phone:503-791-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist