Provider Demographics
NPI:1912742602
Name:LOPEZ REYES, DIANELIS I
Entity type:Individual
Prefix:
First Name:DIANELIS
Middle Name:
Last Name:LOPEZ REYES
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANELIS
Other - Middle Name:
Other - Last Name:LOPEZ REYES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA THERAPY
Mailing Address - Street 1:8300 W FLAGLER ST STE 254C
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-6002
Mailing Address - Country:US
Mailing Address - Phone:786-801-0107
Mailing Address - Fax:
Practice Address - Street 1:17 E 13TH ST APT 1
Practice Address - Street 2:8300 W FLAGLER ST SUITE 254 C
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144
Practice Address - Country:US
Practice Address - Phone:786-801-0107
Practice Address - Fax:786-860-5159
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA102124225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist