Healthcare Provider Details

I. General information

NPI: 1598937047
Provider Name (Legal Business Name): ROBERTO D LOPEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

496 W MAIN ST
EL CENTRO CA
92243-3019
US

IV. Provider business mailing address

496 W. MAIN ST
EL CENTRO CA
92243-3012
US

V. Phone/Fax

Practice location:
  • Phone: 760-352-3336
  • Fax: 760-352-3271
Mailing address:
  • Phone: 760-352-3336
  • Fax: 760-352-3271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number45656
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERTO DANIEL LOPEZ
Title or Position: OWNER
Credential: C. PED., CFO
Phone: 760-352-3336