1114356425 NPI number — LIZET LOPEZ-LONGORIA

Table of content: LIZET LOPEZ-LONGORIA (NPI 1114356425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114356425 NPI number — LIZET LOPEZ-LONGORIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ-LONGORIA
Provider First Name:
LIZET
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114356425
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1490 A GEORGE DIETER,PMB 211
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79936-9685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-319-4803
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5305 MCNUTT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA TERESA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88008-9685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-882-5100
Provider Business Practice Location Address Fax Number:
575-882-1151
Provider Enumeration Date:
11/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  T-0162011 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64153274 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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