Healthcare Provider Details

I. General information

NPI: 1134621857
Provider Name (Legal Business Name): IDA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 CHERRY RIDGE ST STE D400
SAN ANTONIO TX
78230-4820
US

IV. Provider business mailing address

8730 ATWATER CRK
SAN ANTONIO TX
78245-3249
US

V. Phone/Fax

Practice location:
  • Phone: 210-692-0222
  • Fax:
Mailing address:
  • Phone: 956-455-2429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number593318
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: