Provider Demographics
NPI:1649742545
Name:LOPEZ, ISRAEL WILFREDO
Entity Type:Individual
Prefix:
First Name:ISRAEL
Middle Name:WILFREDO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22231 DENKER AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-4114
Mailing Address - Country:US
Mailing Address - Phone:310-972-1639
Mailing Address - Fax:
Practice Address - Street 1:14515 HAMLIN ST STE 103
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1608
Practice Address - Country:US
Practice Address - Phone:818-902-5315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner