MEDICARE: MR. VARDYNG LOPEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	260677758	VA

General Provider Information

NPI Number	:	1154605699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VARDYNG LOPEZ

Provider Business Mailing Address
First Line	:	100 N WASHINGTON ST STE 302
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22046-4516
Country	:	US
Telephone Number	:	703-533-1193
Fax Number	:	703-533-1192

Provider Business Practice Location Address
First Line	:	100 N WASHINGTON ST STE 302
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22046-4516
Country	:	US
Telephone Number	:	703-533-1193
Fax Number	:	703-533-1192

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2011
Last Update Date	:	10/03/2011

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