Healthcare Provider Details

I. General information

NPI: 1316879687
Provider Name (Legal Business Name): EDUARDO JESUS LOPEZ BA, AA-T, CPSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 PARKCENTER DR STE 235
SANTA ANA CA
92705-3588
US

IV. Provider business mailing address

801 PARKCENTER DR STE 235
SANTA ANA CA
92705-3588
US

V. Phone/Fax

Practice location:
  • Phone: 714-948-7980
  • Fax: 657-208-1374
Mailing address:
  • Phone: 714-948-7980
  • Fax: 657-208-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-GCNVWT
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: