Provider Demographics
NPI:1255808432
Name:LOPEZ, JUAN MIGUEL
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:MIGUEL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 DOVEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-5670
Mailing Address - Country:US
Mailing Address - Phone:702-321-5152
Mailing Address - Fax:
Practice Address - Street 1:953 E SAHARA AVE STE A1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3028
Practice Address - Country:US
Practice Address - Phone:702-321-5152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals