Provider Demographics
NPI:1295936219
Name:LOPEZ, JORGE E
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:E
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 SW 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-3636
Mailing Address - Country:US
Mailing Address - Phone:786-388-6036
Mailing Address - Fax:
Practice Address - Street 1:550 SW 69TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-3636
Practice Address - Country:US
Practice Address - Phone:786-388-6036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10478310400000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness