Provider Demographics
NPI:1396413514
Name:LOPEZ, LILLIAN R
Entity Type:Individual
Prefix:
First Name:LILLIAN
Middle Name:R
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 1:5 ROSEHILL PL
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-1752
Mailing Address - Country:US
Mailing Address - Phone:646-305-5405
Mailing Address - Fax:
Practice Address - Street 1:5 ROSEHILL PL
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-1752
Practice Address - Country:US
Practice Address - Phone:646-305-5405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012500225700000X
SC12111225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist