Provider Demographics
NPI:1548726953
Name:LOPEZ, BENNY JOE
Entity type:Individual
Prefix:
First Name:BENNY
Middle Name:JOE
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 1:309 OAK CREEK ESTS
Mailing Address - Street 2:
Mailing Address - City:POTEET
Mailing Address - State:TX
Mailing Address - Zip Code:78065-4019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 OAK CREEK ESTS
Practice Address - Street 2:
Practice Address - City:POTEET
Practice Address - State:TX
Practice Address - Zip Code:78065-4019
Practice Address - Country:US
Practice Address - Phone:830-276-4248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX307105310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility