Provider Demographics
NPI:1689775256
Name:LOPEZ, FAITH R (PT)
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:R
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 AMERICAN BLVD W STE 945
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1162
Mailing Address - Country:US
Mailing Address - Phone:952-835-6653
Mailing Address - Fax:
Practice Address - Street 1:5001 AMERICAN BLVD W STE 945
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-1162
Practice Address - Country:US
Practice Address - Phone:952-835-6653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014022225100000X
AR3732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK14163Medicare ID - Type UnspecifiedMEDICARE MEMBER NUMBER