Provider Demographics
NPI:1225244130
Name:LUCILLE LOPEZ WAGNER R.P.T., INC.
Entity Type:Organization
Organization Name:LUCILLE LOPEZ WAGNER R.P.T., INC.
Other - Org Name:ORANGE COAST PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:LOPEZ
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, LAC
Authorized Official - Phone:714-841-2688
Mailing Address - Street 1:3079 NESTALL RD
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2026
Mailing Address - Country:US
Mailing Address - Phone:949-497-8227
Mailing Address - Fax:714-841-2688
Practice Address - Street 1:17456 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5913
Practice Address - Country:US
Practice Address - Phone:714-841-2688
Practice Address - Fax:714-841-2688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2010-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6997174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14802Medicare ID - Type Unspecified