Healthcare Provider Details

I. General information

NPI: 1710793054
Provider Name (Legal Business Name): LUIS ENRIQUE SOCORRO LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 N TENAYA WAY STE 100
LAS VEGAS NV
89128-0488
US

IV. Provider business mailing address

9792 PIONEER AVE
LAS VEGAS NV
89117-8411
US

V. Phone/Fax

Practice location:
  • Phone: 702-990-7660
  • Fax:
Mailing address:
  • Phone: 702-241-8395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number854668
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: