MEDICARE: JOHN RYAN LOPEZ DE RIVERA PTA

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	225200000X	Physical Therapy Assistant	52710	CA

General Provider Information

NPI Number	:	1821944778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN RYAN LOPEZ DE RIVERA PTA

Provider Business Mailing Address
First Line	:	9301 SHADOWOOD DR APT G
Second Line	:
City	:	MONTCLAIR
State	:	CA
Zip	:	91763-1937
Country	:	US
Telephone Number	:	909-575-7431
Fax Number	:

Provider Business Practice Location Address
First Line	:	4541 PHILADELPHIA ST STE C103
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-2250
Country	:	US
Telephone Number	:	909-590-7997
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2026
Last Update Date	:	03/04/2026

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