Provider Demographics
NPI:1316403637
Name:LOPEZ, JUAN JOSE SR
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:LOPEZ
Suffix:SR
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 1:16138 EUCALYPTUS AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-4786
Mailing Address - Country:US
Mailing Address - Phone:702-324-2537
Mailing Address - Fax:
Practice Address - Street 1:16138 EUCALYPTUS AVE APT 2
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-4786
Practice Address - Country:US
Practice Address - Phone:702-324-2537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD7277584172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver