Basic Information
| Provider Information | |||||||||
| NPI: | 1295733806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | CHRISTINE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 741708 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303741708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523827214 | ||||||||
| FaxNumber: | 3523827781 | ||||||||
| Practice Location | |||||||||
| Address1: | 5481 SW 60TH STREET | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344715638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528731122 | ||||||||
| FaxNumber: | 3528736841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 08/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT18014 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 885813600 | 05 | FL | MEDICAID |