Healthcare Provider Details

I. General information

NPI: 1245545052
Provider Name (Legal Business Name): MADAI LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13169 SOLAR BAY LN
VICTORVILLE CA
92394-9523
US

IV. Provider business mailing address

13169 SOLAR BAY LN
VICTORVILLE CA
92394-9523
US

V. Phone/Fax

Practice location:
  • Phone: 760-373-0471
  • Fax:
Mailing address:
  • Phone: 760-373-0471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT31731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: