Healthcare Provider Details

I. General information

NPI: 1992289060
Provider Name (Legal Business Name): ALEXANDER LOPEZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 SAWGRASS CORPORATE PKWY STE 106
SUNRISE FL
33325-6236
US

IV. Provider business mailing address

440 SAWGRASS CORPORATE PKWY STE 106
SUNRISE FL
33325-6236
US

V. Phone/Fax

Practice location:
  • Phone: 954-745-1112
  • Fax: 954-745-1120
Mailing address:
  • Phone: 954-745-1112
  • Fax: 954-745-1120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number19-79734
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: