MEDICARE: SELENA LOPEZ

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	225400000X	Rehabilitation Practitioner		NV

General Provider Information

NPI Number	:	1861356420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SELENA LOPEZ

Provider Business Mailing Address
First Line	:	4580 S EASTERN AVE STE 33
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6100
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4580 S EASTERN AVE STE 33
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6100
Country	:	US
Telephone Number	:	702-882-7827
Fax Number	:

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

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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Directions to “ SELENA LOPEZ ” Practice Location

Language	Start Address	Practice Location

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