Provider Demographics
NPI:1497438741
Name:LOPEZ, LEOBARDO RUBEN (PTA)
Entity Type:Individual
Prefix:
First Name:LEOBARDO
Middle Name:RUBEN
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 46TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-3517
Mailing Address - Country:US
Mailing Address - Phone:806-942-9382
Mailing Address - Fax:
Practice Address - Street 1:1717 NORFOLK AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-6099
Practice Address - Country:US
Practice Address - Phone:806-281-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2178306225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant