Provider Demographics
NPI:1235674540
Name:LOPEZ, RUBY
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2183 STATE ROAD 1
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-5091
Mailing Address - Country:US
Mailing Address - Phone:575-517-6907
Mailing Address - Fax:
Practice Address - Street 1:2183 STATE ROAD 1
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-5091
Practice Address - Country:US
Practice Address - Phone:575-517-6907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator