Healthcare Provider Details

I. General information

NPI: 1871032466
Provider Name (Legal Business Name): LOPEZ PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4863 PALM COAST PKWY NW UNIT 2&3
PALM COAST FL
32137-3666
US

IV. Provider business mailing address

4863 PALM COAST PKWY NW UNIT 2
PALM COAST FL
32137-3665
US

V. Phone/Fax

Practice location:
  • Phone: 386-222-7746
  • Fax: 904-212-1351
Mailing address:
  • Phone: 910-332-5303
  • Fax: 904-212-1351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME107153
License Number StateFL

VIII. Authorized Official

Name: DR. MANUEL E LOPEZ
Title or Position: OWNER
Credential: M.D.
Phone: 904-707-5498