Healthcare Provider Details

I. General information

NPI: 1578117107
Provider Name (Legal Business Name): INGRID ALEXIS LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9817 VINE ST
BLOOMINGTON CA
92316-2038
US

IV. Provider business mailing address

1556 S SULTANA AVE
ONTARIO CA
91761-4238
US

V. Phone/Fax

Practice location:
  • Phone: 909-647-3053
  • Fax:
Mailing address:
  • Phone: 909-418-6923
  • Fax: 909-418-6937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: