MEDICARE: SUSANA LOPES ATC, LAT

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	2255A2300X	Athletic Trainer	AL3392	FL

General Provider Information

NPI Number	:	1689915027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSANA LOPES ATC, LAT

Provider Business Mailing Address
First Line	:	11652 BENTRY ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-4408
Country	:	US
Telephone Number	:	407-697-4590
Fax Number	:

Provider Business Practice Location Address
First Line	:	11652 BENTRY ST
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32824-4408
Country	:	US
Telephone Number	:	407-697-4590
Fax Number	:

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

Provider Enumeration Date	:	03/11/2013
Last Update Date	:	03/11/2013

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