Provider Demographics
NPI:1558548537
Name:LOPEZ, VIVIANA
Entity Type:Individual
Prefix:MS
First Name:VIVIANA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11080 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1937
Mailing Address - Country:US
Mailing Address - Phone:310-966-6500
Mailing Address - Fax:310-477-7803
Practice Address - Street 1:11080 W OLYMPIC BLVD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1937
Practice Address - Country:US
Practice Address - Phone:310-966-6610
Practice Address - Fax:310-231-0760
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA001612200OtherMEDICAL PIN