Basic Information
Provider Information
NPI: 1003139015
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LOPEZ ORTIZ
FirstName: JUANITA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: RPT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 621
Address2:  
City: AGUAS BUENAS
State: PR
PostalCode: 007030621
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: CARRETERA 173 KM. 8.7
Address2: BARRIO SUMIDERO
City: AGUAS BUENAS
State: PR
PostalCode: 00703
CountryCode: US
TelephoneNumber: 7877320071
FaxNumber: 7877320071
Other Information
ProviderEnumerationDate: 03/04/2010
LastUpdateDate: 04/05/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
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AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X000935PRY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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