Provider Demographics
NPI:1336865229
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 1:18660 LENAIRE DR
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6961
Mailing Address - Country:US
Mailing Address - Phone:786-564-2651
Mailing Address - Fax:
Practice Address - Street 1:7711 N MILITARY TRL
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410-6506
Practice Address - Country:US
Practice Address - Phone:561-460-0284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician