Basic Information
Provider Information | |||||||||
NPI: | 1114114675 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOYA | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | LOPEZ | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3201 W. COMMERCIAL BLVD | ||||||||
Address2: | SUITE 116 C/O CHRISTINE ORTINO | ||||||||
City: | FT. LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 33309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9543324445 | ||||||||
FaxNumber: | 9543324340 | ||||||||
Practice Location | |||||||||
Address1: | 8 THREE RIVERS COURT | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 197024262 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3028361495 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2007 | ||||||||
LastUpdateDate: | 09/28/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J1-0002202 | DE | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.