Provider Demographics
NPI:1518494962
Name:LOPEZ, JUAN (ATC)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-5216
Mailing Address - Country:US
Mailing Address - Phone:516-761-4427
Mailing Address - Fax:
Practice Address - Street 1:1352 HARGUS CREEK RD
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:PA
Practice Address - Zip Code:15370-3814
Practice Address - Country:US
Practice Address - Phone:724-499-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0061462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer