MEDICARE: LESLI MCQUISTON LOPEZ LMT

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	174H00000X	Health Educator	513873	FL
2	225700000X	Massage Therapist	MA 44605	FL

General Provider Information

NPI Number	:	1629342167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLI MCQUISTON LOPEZ LMT

Provider Business Mailing Address
First Line	:	1106 N E ST
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-2063
Country	:	US
Telephone Number	:	561-319-1814
Fax Number	:

Provider Business Practice Location Address
First Line	:	1106 N E ST
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-2063
Country	:	US
Telephone Number	:	561-319-1814
Fax Number	:

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

Provider Enumeration Date	:	03/01/2012
Last Update Date	:	03/01/2012

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