Healthcare Provider Details

I. General information

NPI: 1699806075
Provider Name (Legal Business Name): MR. MAYOLO LOPEZ CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 05/15/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S ST LOUIS ST
LOS ANGELES CA
90033-4320
US

IV. Provider business mailing address

160 S 7TH AVE
LA PUENTE CA
91746-3211
US

V. Phone/Fax

Practice location:
  • Phone: 213-480-1557
  • Fax: 213-480-1182
Mailing address:
  • Phone: 626-961-8971
  • Fax: 626-961-6685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberNONE2
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: