Provider Demographics
NPI:1053110296
Name:LOPEZ, RENE
Entity type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6194 147TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-8986
Mailing Address - Country:US
Mailing Address - Phone:616-312-5316
Mailing Address - Fax:616-294-1122
Practice Address - Street 1:6194 147TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-8986
Practice Address - Country:US
Practice Address - Phone:616-312-5316
Practice Address - Fax:616-294-1122
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF0303975653747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant