Provider Demographics
NPI:1093606717
Name:LOPEZ, SERGIO
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10390 COMMERCE CENTER DR STE 150
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5864
Mailing Address - Country:US
Mailing Address - Phone:909-688-6278
Mailing Address - Fax:
Practice Address - Street 1:17130 SEQUOIA ST STE 104
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1827
Practice Address - Country:US
Practice Address - Phone:909-688-6278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker