MEDICARE: FREDERICK LOPEZ LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1306598297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDERICK LOPEZ LLC

Provider Business Mailing Address
First Line	:	27162 GOLDEN FIELD CT
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92555-4538
Country	:	US
Telephone Number	:	909-251-2449
Fax Number	:	909-494-4208

Provider Business Practice Location Address
First Line	:	1012 E COOLEY DR STE B2
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-3959
Country	:	US
Telephone Number	:	951-567-1135
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. FREDERICK LOPEZ
Credential	:	PSY32140
Telephone Number	:	909-251-2449

Provider Enumeration Date	:	01/21/2022
Last Update Date	:	03/04/2024

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