1922424985 NPI number — ISIS KARENSHA LOPEZ

Table of content: ISIS KARENSHA LOPEZ (NPI 1922424985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922424985 NPI number — ISIS KARENSHA LOPEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
ISIS
Provider Middle Name:
KARENSHA
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:
1922424985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1223 NE BARAGAR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-236-5997
Provider Business Mailing Address Fax Number:
541-236-5291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1223 NE BARAGAR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471-5621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-236-5997
Provider Business Practice Location Address Fax Number:
541-236-5291
Provider Enumeration Date:
03/13/2014

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: 174400000X , with the licence number:  17016 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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