Provider Demographics
NPI:1104020429
Name:LOPEZ DIAZ, NICOLAS
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:LOPEZ DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ACTIVE
Other - Middle Name:AMBULANCE
Other - Last Name:SERVICE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:400 AVE. PENSILVANNIA APARTADO # 406
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:PR
Mailing Address - Zip Code:00751
Mailing Address - Country:US
Mailing Address - Phone:787-448-0911
Mailing Address - Fax:787-824-7738
Practice Address - Street 1:URB. LA ARBOLEDA 349 CALLE 15
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:PR
Practice Address - Zip Code:00751
Practice Address - Country:US
Practice Address - Phone:787-448-0911
Practice Address - Fax:787-824-7738
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2003476146N00000X
PRTCAMB4573416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0058546Medicare PIN