Basic Information
| Provider Information | |||||||||
| NPI: | 1124648621 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | MARITZA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9570 CENTER AVE STE 110 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917305842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099802789 | ||||||||
| FaxNumber: | 9099802689 | ||||||||
| Practice Location | |||||||||
| Address1: | 9570 CENTER AVE STE 110 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917305842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099802789 | ||||||||
| FaxNumber: | 9099802689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2020 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 175T00000X | Y |
No ID Information.