Basic Information
| Provider Information | |||||||||
| NPI: | 1174137897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | LEANDRO | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 709 S HARBOR CITY BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217227225 | ||||||||
| FaxNumber: | 3213080635 | ||||||||
| Practice Location | |||||||||
| Address1: | 4311 NORFOLK PKWY STE 116 | ||||||||
| Address2: | |||||||||
| City: | WEST MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329048617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218025816 | ||||||||
| FaxNumber: | 3218025811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2020 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305213872 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT31915 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.