=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407354558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDRA GABRIELA LOPEZ LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2018
-----------------------------------------------------
Last Update Date | 03/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5165 S FORT APACHE RD STE 180
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89148-1764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-981-8773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7719 CRYSTAL VILLAGE LN
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89113-3242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-405-3681
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | NVMT.6292
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------