Provider Demographics
NPI:1548989601
Name:LOPEZ, THEODORE JAKOB (DPT)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:JAKOB
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5718
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-5718
Mailing Address - Country:US
Mailing Address - Phone:406-756-0134
Mailing Address - Fax:406-300-1612
Practice Address - Street 1:11100 HIGHWAY 165 STE 5
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-9781
Practice Address - Country:US
Practice Address - Phone:501-945-0200
Practice Address - Fax:501-945-0245
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT5197225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist