Healthcare Provider Details

I. General information

NPI: 1497438519
Provider Name (Legal Business Name): ALEXANDRA MARET LOPEZ ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 11/30/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 US HWY 11 UWA STATION 14
LIVINGSTON AL
34570
US

IV. Provider business mailing address

100 US 11 UWA STATION 14
LIVINGSTON AL
34570
US

V. Phone/Fax

Practice location:
  • Phone: 205-652-3714
  • Fax:
Mailing address:
  • Phone: 205-652-3714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: