Basic Information
| Provider Information | |||||||||
| NPI: | 1306384664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | LAT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2703 LEVICK ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191492941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157587408 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 ALMSHOUSE ROAD | ||||||||
| Address2: | |||||||||
| City: | RICHBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153572000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2017 | ||||||||
| LastUpdateDate: | 02/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | RTO000230 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2255A2300X | 25MT00217000 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.