Provider Demographics
NPI:1689105686
Name:LOPEZ, JUAN CARLOS (ATC)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
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 1:5599 GREENOAKS DR
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-3846
Mailing Address - Country:US
Mailing Address - Phone:209-613-5130
Mailing Address - Fax:
Practice Address - Street 1:2357 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5239
Practice Address - Country:US
Practice Address - Phone:209-477-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor