=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871032466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOPEZ PAIN MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2017
-----------------------------------------------------
Last Update Date | 07/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4863 PALM COAST PKWY NW UNIT 2&3
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-3666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-222-7746
-----------------------------------------------------
Fax | 904-212-1351
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4863 PALM COAST PKWY NW UNIT 2
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-3665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-332-5303
-----------------------------------------------------
Fax | 904-212-1351
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MANUEL E LOPEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 904-707-5498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | ME107153
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------