Provider Demographics
NPI:1285704064
Name:LOPEZ, JUAN JOSE (DC)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:JOSE
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-3804
Mailing Address - Country:US
Mailing Address - Phone:510-357-3514
Mailing Address - Fax:
Practice Address - Street 1:433 CALLAN AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4643
Practice Address - Country:US
Practice Address - Phone:510-357-3514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27475111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU84859Medicare UPIN
CADC0274750Medicare ID - Type Unspecified