Provider Demographics
NPI:1629478789
Name:ORTIZ LOPEZ, JUAN A
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:A
Last Name:ORTIZ LOPEZ
Suffix:
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 1:3592 SANCTUARY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-7122
Mailing Address - Country:US
Mailing Address - Phone:321-746-0778
Mailing Address - Fax:
Practice Address - Street 1:148 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5372
Practice Address - Country:US
Practice Address - Phone:407-978-6085
Practice Address - Fax:321-445-9760
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician