Healthcare Provider Details

I. General information

NPI: 1891976882
Provider Name (Legal Business Name): MR. ERIC EDWARDS LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2007
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 E SHAW AVE STE 102
FRESNO CA
93710-7616
US

IV. Provider business mailing address

1848 SE 1ST AVE
FORT LAUDERDALE FL
33316
US

V. Phone/Fax

Practice location:
  • Phone: 559-226-0167
  • Fax: 559-226-1559
Mailing address:
  • Phone: 954-885-9500
  • Fax: 954-885-9444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY10006
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: