Basic Information
| Provider Information | |||||||||
| NPI: | 1083211155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 828 MARYESS DR | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924102739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096451050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4000 N PEPPR AVE. | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095801000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2020 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86075008 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.