Healthcare Provider Details

I. General information

NPI: 1972294809
Provider Name (Legal Business Name): RICHARD LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 NORTH LOOP RD
FORT IRWIN CA
92310
US

IV. Provider business mailing address

390 NORTH LOOP RD
FORT IRWIN CA
92310
US

V. Phone/Fax

Practice location:
  • Phone: 760-383-5289
  • Fax:
Mailing address:
  • Phone: 626-945-7367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number136967
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: