Provider Demographics
NPI:1790773125
Name:LOPEZ, JOE (ATC)
Entity Type:Individual
Prefix:
First Name:JOE
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 1:2598 S BUCKAROO TRL
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-6576
Mailing Address - Country:US
Mailing Address - Phone:602-790-9808
Mailing Address - Fax:
Practice Address - Street 1:2598 S BUCKAROO TRL
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-6576
Practice Address - Country:US
Practice Address - Phone:602-790-9808
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0373OtherSTATE LICENSE