Healthcare Provider Details

I. General information

NPI: 1306580576
Provider Name (Legal Business Name): JORGE LUIS LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12702 TOEPPERWEIN RD STE 120
LIVE OAK TX
78233-3208
US

IV. Provider business mailing address

1420 ANHALT DR # 50B
PFLUGERVILLE TX
78660-6110
US

V. Phone/Fax

Practice location:
  • Phone: 210-653-4420
  • Fax:
Mailing address:
  • Phone: 915-240-0866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: