Healthcare Provider Details

I. General information

NPI: 1811137664
Provider Name (Legal Business Name): JUAN F LOPEZ MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2009
Last Update Date: 03/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 W 49 PL SUITE 210
HIALEAH FL
33012
US

IV. Provider business mailing address

1490 W 49TH PL SUITE 210
HIALEAH FL
33012-3148
US

V. Phone/Fax

Practice location:
  • Phone: 305-823-4008
  • Fax: 305-823-4009
Mailing address:
  • Phone: 305-823-4008
  • Fax: 305-823-4009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberMA 51137
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: