Healthcare Provider Details

I. General information

NPI: 1134433477
Provider Name (Legal Business Name): MATEO LORENZO LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94-1007 HIAPO ST
WAIPAHU HI
96797-3709
US

IV. Provider business mailing address

94-1007 HIAPO ST
WAIPAHU HI
96797-3709
US

V. Phone/Fax

Practice location:
  • Phone: 808-688-8033
  • Fax: 808-772-4316
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: