Healthcare Provider Details

I. General information

NPI: 1336079987
Provider Name (Legal Business Name): AMANDA NICOLE LOPEZ OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 GRAND AVE STE A
CHINO CA
91710-5492
US

IV. Provider business mailing address

16201 PORTER AVE
RIVERSIDE CA
92504-6006
US

V. Phone/Fax

Practice location:
  • Phone: 909-664-0057
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: