Healthcare Provider Details

I. General information

NPI: 1104590470
Provider Name (Legal Business Name): RAYMOND LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14677 MERRILL AVE
FONTANA CA
92335-4219
US

IV. Provider business mailing address

8950 MAGNOLIA AVE UNIT 213
MONTCLAIR CA
91763-1461
US

V. Phone/Fax

Practice location:
  • Phone: 951-643-2340
  • Fax:
Mailing address:
  • Phone: 909-605-3303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number42062
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: