Healthcare Provider Details

I. General information

NPI: 1467774174
Provider Name (Legal Business Name): JUAN CARLOS LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2010
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

679 S NEW HAMPSHIRE AVE
LOS ANGELES CA
90005-1355
US

IV. Provider business mailing address

2325 LANCE ST
MERCED CA
95348-3739
US

V. Phone/Fax

Practice location:
  • Phone: 213-385-5100
  • Fax:
Mailing address:
  • Phone: 209-617-3460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: