Provider Demographics
NPI:1154676112
Name:LOPEZ, EDGAR (LVN)
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3392 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-1882
Mailing Address - Country:US
Mailing Address - Phone:714-396-1797
Mailing Address - Fax:
Practice Address - Street 1:3392 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-1882
Practice Address - Country:US
Practice Address - Phone:714-396-1797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN238302164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse