Healthcare Provider Details

I. General information

NPI: 1922424985
Provider Name (Legal Business Name): ISIS KARENSHA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 NE BARAGAR AVE
ROSEBURG OR
97471-5621
US

IV. Provider business mailing address

1223 NE BARAGAR AVE
ROSEBURG OR
97470
US

V. Phone/Fax

Practice location:
  • Phone: 541-236-5997
  • Fax: 541-236-5291
Mailing address:
  • Phone: 541-236-5997
  • Fax: 541-236-5291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number17016
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: