Provider Demographics
NPI: | 1821202870 |
---|---|
Name: | CONCHITALOPEZ |
Entity Type: | Organization |
Organization Name: | CONCHITALOPEZ |
Other - Org Name: | CONCHITALOPEZ |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | I.P. |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | CONCHITA |
Authorized Official - Middle Name: | ELEENA |
Authorized Official - Last Name: | LOPEZ |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 614-235-3581 |
Mailing Address - Street 1: | 3122 SCOTTWOOD RD |
Mailing Address - Street 2: | |
Mailing Address - City: | COLUMBUS |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 43227-3446 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 614-235-3581 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3122 SCOTTWOOD RD |
Practice Address - Street 2: | |
Practice Address - City: | COLUMBUS |
Practice Address - State: | OH |
Practice Address - Zip Code: | 43227-3446 |
Practice Address - Country: | US |
Practice Address - Phone: | 614-235-3581 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-05-09 |
Last Update Date: | 2008-08-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 374U00000X | Nursing Service Related Providers | Home Health Aide | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 2078960 | Medicaid |