1487875647 NPI number — CORI R LOPEZ DO

Table of content: CORI R LOPEZ DO (NPI 1487875647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487875647 NPI number — CORI R LOPEZ DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
CORI
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARRIS
Provider Other First Name:
CORI
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487875647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3649
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99220-3649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 N 7TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHENEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-838-2531
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2007

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: 207Q00000X , with the licence number:  OP00002115 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 221693 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8483364 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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