Healthcare Provider Details

I. General information

NPI: 1356695944
Provider Name (Legal Business Name): JUSTEN JOSEPH LOPEZ ATC, LAT, PES, GTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2012
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 GLENVILLE ST
GREENWICH CT
06831-3680
US

IV. Provider business mailing address

10 GLENVILLE ST
GREENWICH CT
06831-3680
US

V. Phone/Fax

Practice location:
  • Phone: 518-258-9828
  • Fax:
Mailing address:
  • Phone: 518-258-9828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 3159
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1602
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number002612
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: