Healthcare Provider Details

I. General information

NPI: 1669895918
Provider Name (Legal Business Name): JOSHUA JAMES LOPEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E SOUTHERN AVE STE 310
TEMPE AZ
85282-5695
US

IV. Provider business mailing address

17224 E GRANDE BLVD
FOUNTAIN HILLS AZ
85268-3225
US

V. Phone/Fax

Practice location:
  • Phone: 602-567-9881
  • Fax:
Mailing address:
  • Phone: 480-767-3158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number9682A
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: