MEDICARE: DR. ROBERT LEON LOPEZ D.C.

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	111N00000X	Chiropractor	864	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P0086830	OTHER	AZ	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1295722775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT LEON LOPEZ D.C.

Provider Business Mailing Address
First Line	:	4527 S HWY 92
Second Line	:
City	:	SIERRA VISTA
State	:	AZ
Zip	:	85650-9624
Country	:	US
Telephone Number	:	520-378-2777
Fax Number	:	520-378-2780

Provider Business Practice Location Address
First Line	:	4527 S HWY 92
Second Line	:
City	:	SIERRA VISTA
State	:	AZ
Zip	:	85650-9624
Country	:	US
Telephone Number	:	520-378-2777
Fax Number	:	520-378-2780

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	10/04/2007

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