1366080087 NPI number — PRISCILLA C LOPEZ MASTER CASAC #34980

Table of content: PRISCILLA C LOPEZ MASTER CASAC #34980 (NPI 1366080087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366080087 NPI number — PRISCILLA C LOPEZ MASTER CASAC #34980

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
PRISCILLA
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MASTER CASAC #34980
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:
1366080087
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
131 SAINT NICHOLAS AVE APT 2D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10026-2147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-270-7141
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3584 JEROME AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10467-1006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
653-153-7718
Provider Business Practice Location Address Fax Number:
699-371-8228
Provider Enumeration Date:
12/12/2019

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: 101YA0400X , with the licence number:  211110743 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11681 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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