Provider Demographics
NPI:1104010008
Name:LOPEZ, MARIO MARCHAN (BA)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:MARCHAN
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10182 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5304
Mailing Address - Country:US
Mailing Address - Phone:951-452-2356
Mailing Address - Fax:
Practice Address - Street 1:10182 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5304
Practice Address - Country:US
Practice Address - Phone:951-452-2356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator