Healthcare Provider Details

I. General information

NPI: 1790019545
Provider Name (Legal Business Name): JOSE JULIAN LOPEZ L.S.A.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COUNTY ROAD 41 PVT DRIVE 1098
VELARDE NM
87582
US

IV. Provider business mailing address

P.O BOX 520
ESPANOLA NM
87532
US

V. Phone/Fax

Practice location:
  • Phone: 505-852-2580
  • Fax: 505-852-1827
Mailing address:
  • Phone: 505-852-2580
  • Fax: 505-852-1827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0064231
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: