Healthcare Provider Details

I. General information

NPI: 1124228721
Provider Name (Legal Business Name): JAIME M LOPEZ JR. CST/CFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 ENGLEWOOD LN
ODESSA TX
79761-3324
US

IV. Provider business mailing address

1430 ENGLEWOOD LN
ODESSA TX
79761-3324
US

V. Phone/Fax

Practice location:
  • Phone: 432-272-1185
  • Fax:
Mailing address:
  • Phone: 432-272-1185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number105233
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: