Provider Demographics
NPI:1902598386
Name:LOPEZ, BETHANY (ABO, NCLE, LDO)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:ABO, NCLE, LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6261 REVELSTOKE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-2044
Mailing Address - Country:US
Mailing Address - Phone:719-330-4085
Mailing Address - Fax:
Practice Address - Street 1:707 S 8TH ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1811
Practice Address - Country:US
Practice Address - Phone:719-633-1044
Practice Address - Fax:719-633-1109
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDIO-407156FX1800X
072634156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician