Healthcare Provider Details

I. General information

NPI: 1508497504
Provider Name (Legal Business Name): RICARDO LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11900 AVALON BLVD STE 101
LOS ANGELES CA
90061-2867
US

IV. Provider business mailing address

2551 MALABAR ST
LOS ANGELES CA
90033-2525
US

V. Phone/Fax

Practice location:
  • Phone: 323-880-8048
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: