MEDICARE: LEILANI A LOPEZ P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	019000	NY

General Provider Information

NPI Number	:	1033171566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEILANI A LOPEZ P.T.

Provider Business Mailing Address
First Line	:	1377 MOTOR PKWY
Second Line	:	STE 307
City	:	ISLANDIA
State	:	NY
Zip	:	11749-5258
Country	:	US
Telephone Number	:	845-278-8400
Fax Number	:	845-278-4326

Provider Business Practice Location Address
First Line	:	667 STONELEIGH AVE
Second Line	:	SUITE 117
City	:	CARMEL
State	:	NY
Zip	:	10512-2454
Country	:	US
Telephone Number	:	845-230-5178
Fax Number	:	845-363-1816

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	09/07/2018

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