Healthcare Provider Details

I. General information

NPI: 1457972069
Provider Name (Legal Business Name): RAUL ADAM LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 S WESTLAKE AVE
LOS ANGELES CA
90057-2906
US

IV. Provider business mailing address

3125 E 7TH ST
LONG BEACH CA
90804-4932
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-9202
  • Fax:
Mailing address:
  • Phone: 562-271-2263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: