Healthcare Provider Details

I. General information

NPI: 1265797385
Provider Name (Legal Business Name): ROBERTO LOPEZ JR. D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4177 S ARCHER AVE
CHICAGO IL
60632-1849
US

IV. Provider business mailing address

5816 S KILDARE AVE
CHICAGO IL
60629-4935
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-2222
  • Fax: 773-376-1162
Mailing address:
  • Phone: 773-962-7892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038012211
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: