MEDICARE: CONRAD D LOPEZ JR. PT

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	024920	NY

General Provider Information

NPI Number	:	1841320777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONRAD D LOPEZ JR. PT

Provider Business Mailing Address
First Line	:	8685 102ND ST
Second Line	:
City	:	RICHMOND HILL
State	:	NY
Zip	:	11418-2033
Country	:	US
Telephone Number	:	718-846-5493
Fax Number	:

Provider Business Practice Location Address
First Line	:	7241 GRAND AVE
Second Line	:
City	:	MASPETH
State	:	NY
Zip	:	11378-1532
Country	:	US
Telephone Number	:	718-457-5800
Fax Number	:

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	04/15/2013

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