Healthcare Provider Details

I. General information

NPI: 1689077182
Provider Name (Legal Business Name): EDDIE LOPEZ JR. MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2014
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 TECHNOLOGY CT
RIVERSIDE CA
92507-2155
US

IV. Provider business mailing address

2085 RUSTIN AVE
RIVERSIDE CA
92507-2498
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-8500
  • Fax:
Mailing address:
  • Phone: 951-715-5040
  • Fax: 951-784-4976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103771
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: