Healthcare Provider Details

I. General information

NPI: 1497958045
Provider Name (Legal Business Name): MICHAEL LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 TRAVIS BLVD
FAIRFIELD CA
94533-3803
US

IV. Provider business mailing address

315 MOORLAND ST
VALLEJO CA
94590-3530
US

V. Phone/Fax

Practice location:
  • Phone: 707-673-2838
  • Fax:
Mailing address:
  • Phone: 707-558-1777
  • Fax: 707-558-1770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: