Healthcare Provider Details

I. General information

NPI: 1144883448
Provider Name (Legal Business Name): LUIS LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2563 MAST WAY STE 202
CHULA VISTA CA
91914-4539
US

IV. Provider business mailing address

2563 MAST WAY STE 202
CHULA VISTA CA
91914-4539
US

V. Phone/Fax

Practice location:
  • Phone: 619-587-0015
  • Fax:
Mailing address:
  • Phone: 619-587-0015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number236559863
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: