Provider Demographics
NPI:1720788466
Name:LOPEZ, RAMON ANGEL (CEO)
Entity Type:Individual
Prefix:
First Name:RAMON
Middle Name:ANGEL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:RAMON
Other - Middle Name:ANGEL
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:INDEPENDENT FUT LLC
Mailing Address - Street 1:2239 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:COOLIDGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85128-3231
Mailing Address - Country:US
Mailing Address - Phone:520-858-6631
Mailing Address - Fax:
Practice Address - Street 1:2239 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:AZ
Practice Address - Zip Code:85128-3231
Practice Address - Country:US
Practice Address - Phone:520-858-6631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZQ02202313746251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services