MEDICARE: JEFFREY 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	251S00000X	Community/Behavioral Health Agency		FL

General Provider Information

NPI Number	:	1881186963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY LOPEZ

Provider Business Mailing Address
First Line	:	17670 NW 78TH AVE STE 111
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-3665
Country	:	US
Telephone Number	:	786-806-7987
Fax Number	:

Provider Business Practice Location Address
First Line	:	17670 NW 78TH AVE STE 111
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-3665
Country	:	US
Telephone Number	:	786-806-7987
Fax Number	:

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

Provider Enumeration Date	:	06/04/2018
Last Update Date	:	06/04/2018

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Directions to “ JEFFREY LOPEZ ” Practice Location

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