Basic Information
| Provider Information | |||||||||
| NPI: | 1821219320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | RICARDO | ||||||||
| MiddleName: | JOSE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1240 W. BETHEL LN. #27B | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059259811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 S. MILLER ST. SUITE 101&102 | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059259811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 42AC | 05 | CA | MEDICAID |