MEDICARE: LUCILLE LOPEZ WAGNER R.P.T., INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	PT6997	CA

General Provider Information

NPI Number	:	1225244130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUCILLE LOPEZ WAGNER R.P.T., INC.

Provider Business Mailing Address
First Line	:	3079 NESTALL RD
Second Line	:
City	:	LAGUNA BEACH
State	:	CA
Zip	:	92651-2026
Country	:	US
Telephone Number	:	949-497-8227
Fax Number	:	714-841-2688

Provider Business Practice Location Address
First Line	:	17456 BEACH BLVD
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-5913
Country	:	US
Telephone Number	:	714-841-2688
Fax Number	:	714-841-2688

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. LUCILLE LOPEZ WAGNER
Credential	:	P.T., L.AC.
Telephone Number	:	714-841-2688

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	08/29/2010

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