Healthcare Provider Details

I. General information

NPI: 1699801258
Provider Name (Legal Business Name): MR. ELIEGO LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3637 MISSION AVE BLDG B
CARMICHAEL CA
95608-2946
US

IV. Provider business mailing address

3628 MADISON AVE
NORTH HIGHLANDS CA
95660-5069
US

V. Phone/Fax

Practice location:
  • Phone: 916-485-4175
  • Fax: 916-485-2673
Mailing address:
  • Phone: 916-388-3231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: