Healthcare Provider Details

I. General information

NPI: 1154231363
Provider Name (Legal Business Name): CARLOS GAIZKA ANSOLEAGA LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 W HART RD
BELOIT WI
53511-2230
US

IV. Provider business mailing address

1234 PARTRIDGE AVE
BELOIT WI
53511-4748
US

V. Phone/Fax

Practice location:
  • Phone: 608-365-2554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4402-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: