Healthcare Provider Details

I. General information

NPI: 1164291415
Provider Name (Legal Business Name): ANTONIO LOPEZ JR. DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2023
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N110 BRUX RD
APPLETON WI
54915-9439
US

IV. Provider business mailing address

N110 BRUX RD
APPLETON WI
54915-9439
US

V. Phone/Fax

Practice location:
  • Phone: 920-968-0464
  • Fax:
Mailing address:
  • Phone: 920-968-0464
  • Fax: 920-968-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number6275-12
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: