1255597472 NPI number — MR. ERNESTO LOPEZ GRECIA JR. PT

Table of content: MR. ERNESTO LOPEZ GRECIA JR. PT (NPI 1255597472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255597472 NPI number — MR. ERNESTO LOPEZ GRECIA JR. PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRECIA
Provider First Name:
ERNESTO
Provider Middle Name:
LOPEZ
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1255597472
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
EXECUTIVE CENTER II, 3290 NORTH RIDGE ROAD
Provider Second Line Business Mailing Address:
SUITE 290
Provider Business Mailing Address City Name:
ELLICOTT
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-292-4008
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
EXECUTIVE CENTER II, 3290 NORTH RIDGE ROAD
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
ELLICOTT
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-292-4008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2008

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: 225100000X , with the licence number:  22583 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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