Healthcare Provider Details

I. General information

NPI: 1689048258
Provider Name (Legal Business Name): ELIAS SAMUEL LOPEZ MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 CALLE MONSERRATE
SAN JUAN PR
00907-4511
US

IV. Provider business mailing address

PO BOX 3382
RIO GRANDE PR
00745-3382
US

V. Phone/Fax

Practice location:
  • Phone: 787-724-4051
  • Fax:
Mailing address:
  • Phone: 787-988-5349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12849
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: