Provider Demographics
NPI:1598862922
Name:LOPEZ, RICARDO M (RPT)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2016 VANDERBILT LN
Mailing Address - Street 2:#4
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-3058
Mailing Address - Country:US
Mailing Address - Phone:310-374-7609
Mailing Address - Fax:
Practice Address - Street 1:2121 WILSHIRE BL.
Practice Address - Street 2:STE 102
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-828-6454
Practice Address - Fax:310-828-2001
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT25550OtherPHYSICAL THERAPY LICENSE