Healthcare Provider Details

I. General information

NPI: 1033668074
Provider Name (Legal Business Name): ROBERT LOPEZ EXTENDER PLUS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4451 NE 30TH TER
LIGHTHOUSE POINT FL
33064-7229
US

IV. Provider business mailing address

4451 NE 30TH TER
LIGHTHOUSE POINT FL
33064-7229
US

V. Phone/Fax

Practice location:
  • Phone: 745-800-7730
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: ROBERT LOPEZ
Title or Position: OWNER
Credential:
Phone: 754-800-7730