Healthcare Provider Details

I. General information

NPI: 1528767647
Provider Name (Legal Business Name): OMAR LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6051 N FRESNO ST STE 202
FRESNO CA
93710-5280
US

IV. Provider business mailing address

1396 W HERNDON AVE
FRESNO CA
93711-7126
US

V. Phone/Fax

Practice location:
  • Phone: 559-818-4750
  • Fax:
Mailing address:
  • Phone: 559-256-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: