MEDICARE: MRS. ELBA LOPEZ RPT

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	739	PR

General Provider Information

NPI Number	:	1104818509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELBA LOPEZ RPT

Provider Business Mailing Address
First Line	:	302 CALLE DR HERNANDEZ DEL VALLE
Second Line	:
City	:	ISABELA
State	:	PR
Zip	:	00662-3919
Country	:	US
Telephone Number	:	787-872-0415
Fax Number	:	787-872-0415

Provider Business Practice Location Address
First Line	:	7353 AVE RAMOS CALERO
Second Line	:	A
City	:	ISABELA
State	:	PR
Zip	:	00662-3500
Country	:	US
Telephone Number	:	787-872-0415
Fax Number	:	787-872-0415

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

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	07/08/2007

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