1447795729 NPI number — LOPEZ SEPULVEDA PRIMARY CARE PLLC

Table of content: (NPI 1447795729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447795729 NPI number — LOPEZ SEPULVEDA PRIMARY CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOPEZ SEPULVEDA PRIMARY CARE PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLINICA TU SALUD
Provider Other Organization Name Type Code:
3
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:
1447795729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 E GRAUWYLER RD STE 122
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75061-2639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-887-3235
Provider Business Mailing Address Fax Number:
972-887-3197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 E GRAUWYLER RD
Provider Second Line Business Practice Location Address:
SUITE 122
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75061-2639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-887-3235
Provider Business Practice Location Address Fax Number:
972-887-3197
Provider Enumeration Date:
12/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ SEPULVEDA
Authorized Official First Name:
JAXEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
972-887-3235

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  Q5020 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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