MEDICARE: THEODORE JAKOB LOPEZ DPT

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	225100000X	Physical Therapist	PT5197	AR

General Provider Information

NPI Number	:	1548989601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODORE JAKOB LOPEZ DPT

Provider Business Mailing Address
First Line	:	PO BOX 5718
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59903-5718
Country	:	US
Telephone Number	:	406-756-0134
Fax Number	:	406-300-1612

Provider Business Practice Location Address
First Line	:	11100 HIGHWAY 165 STE 5
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72117-9781
Country	:	US
Telephone Number	:	501-945-0200
Fax Number	:	501-945-0245

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

Provider Enumeration Date	:	08/23/2022
Last Update Date	:	08/23/2022

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