Provider Demographics
NPI:1982171815
Name:LOPEZ, ENRIQUE (BA)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3843 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4623
Mailing Address - Country:US
Mailing Address - Phone:773-884-2297
Mailing Address - Fax:773-884-0003
Practice Address - Street 1:3843 W 63RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4623
Practice Address - Country:US
Practice Address - Phone:773-884-2297
Practice Address - Fax:773-884-0003
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator