Provider Demographics
NPI:1720765787
Name:LOPEZ, JOSE LUIS
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
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 1:124 W ELIZONDO ST
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-4218
Mailing Address - Country:US
Mailing Address - Phone:956-573-8126
Mailing Address - Fax:
Practice Address - Street 1:408 N FLORES ST UNIT R
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-3745
Practice Address - Country:US
Practice Address - Phone:956-573-8126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications