Healthcare Provider Details

I. General information

NPI: 1205267739
Provider Name (Legal Business Name): ENRIQUE J LOPEZ DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6850 BROCKTON AVE SUITE 212
RIVERSIDE CA
92506-3808
US

IV. Provider business mailing address

24630 WASHINGTON AVE SUITE 200
MURRIETA CA
92562-6131
US

V. Phone/Fax

Practice location:
  • Phone: 951-534-0600
  • Fax: 951-534-0605
Mailing address:
  • Phone: 951-696-9353
  • Fax: 951-973-7216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT40785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: