Basic Information
| Provider Information | |||||||||
| NPI: | 1801553524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | JORDAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27 S 100 W | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463859054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193817880 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2906 HIGHWAY AVE | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463221631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2195138311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2021 | ||||||||
| LastUpdateDate: | 11/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y | 193200000X MULTI-SPECIALTY GROUP |
No ID Information.