Healthcare Provider Details

I. General information

NPI: 1023463569
Provider Name (Legal Business Name): ALEJANDRO LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BROADWAY ST
VANCOUVER WA
98663-3229
US

IV. Provider business mailing address

2400 BROADWAY ST
VANCOUVER WA
98663-3229
US

V. Phone/Fax

Practice location:
  • Phone: 360-910-8748
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number60445200
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: