Provider Demographics
NPI:1972777654
Name:ANGEL LOPEZ CLINIC, INC.
Entity Type:Organization
Organization Name:ANGEL LOPEZ CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCCHECHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-232-0555
Mailing Address - Street 1:2250 SATELLITE BLVD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097
Mailing Address - Country:US
Mailing Address - Phone:770-232-0555
Mailing Address - Fax:770-232-0640
Practice Address - Street 1:2250 SATELLITE BLVD
Practice Address - Street 2:SUITE 175
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097
Practice Address - Country:US
Practice Address - Phone:770-232-0555
Practice Address - Fax:770-232-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA018244591BMedicaid