Healthcare Provider Details

I. General information

NPI: 1750115168
Provider Name (Legal Business Name): MS. DIANA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WESTWARD DR STE 103
MIAMI SPRINGS FL
33166-5211
US

IV. Provider business mailing address

6544 SW 73RD CT
MIAMI FL
33143-2919
US

V. Phone/Fax

Practice location:
  • Phone: 305-290-0622
  • Fax:
Mailing address:
  • Phone: 305-803-6682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA28238
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: