1932316593 NPI number — DR. ROSALBA M LOPEZ DE VAUGHAN PH.D.

Table of content: DR. ROSALBA M LOPEZ DE VAUGHAN PH.D. (NPI 1932316593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932316593 NPI number — DR. ROSALBA M LOPEZ DE VAUGHAN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ DE VAUGHAN
Provider First Name:
ROSALBA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1932316593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
381 W NORTHWEST HWY
Provider Second Line Business Mailing Address:
SUCCESSFUL LONGEVITY CLINIC
Provider Business Mailing Address City Name:
PALATINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60067-2414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-705-7199
Provider Business Mailing Address Fax Number:
847-705-7112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
381 W NORTHWEST HWY
Provider Second Line Business Practice Location Address:
SUCCESSFUL LONGEVITY CLINIC
Provider Business Practice Location Address City Name:
PALATINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60067-2414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-705-7199
Provider Business Practice Location Address Fax Number:
847-705-7112
Provider Enumeration Date:
05/16/2007

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: 171100000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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