Healthcare Provider Details

I. General information

NPI: 1114114675
Provider Name (Legal Business Name): JENNIFER LOPEZ MOYA RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 THREE RIVERS COURT
NEWARK DE
19702-4262
US

IV. Provider business mailing address

3201 W. COMMERCIAL BLVD SUITE 116 C/O CHRISTINE ORTINO
FT. LAUDERDALE FL
33309
US

V. Phone/Fax

Practice location:
  • Phone: 302-836-1495
  • Fax:
Mailing address:
  • Phone: 954-332-4445
  • Fax: 954-332-4340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0002202
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: