Basic Information
| Provider Information | |||||||||
| NPI: | 1104590470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | RAYMOND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8950 MAGNOLIA AVE UNIT 213 | ||||||||
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| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917631461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096053303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14677 MERRILL AVE | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923354219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516432340 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2021 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 42062 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.