Healthcare Provider Details

I. General information

NPI: 1255808432
Provider Name (Legal Business Name): JUAN MIGUEL LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 E SAHARA AVE STE A1
LAS VEGAS NV
89104-3028
US

IV. Provider business mailing address

30 DOVEWOOD AVE
LAS VEGAS NV
89183-5670
US

V. Phone/Fax

Practice location:
  • Phone: 702-321-5152
  • Fax:
Mailing address:
  • Phone: 702-321-5152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: