Healthcare Provider Details

I. General information

NPI: 1306675798
Provider Name (Legal Business Name): JOHNNY RAY LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13139 CENTRAL AVE NE
ALBUQUERQUE NM
87123-3031
US

IV. Provider business mailing address

13139 CENTRAL AVE NE
ALBUQUERQUE NM
87123-3031
US

V. Phone/Fax

Practice location:
  • Phone: 505-595-1607
  • Fax:
Mailing address:
  • Phone: 505-595-1607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: