Provider Demographics
NPI:1699806075
Name:LOPEZ CHAVEZ, MAYOLO
Entity Type:Individual
Prefix:MR
First Name:MAYOLO
Middle Name:
Last Name:LOPEZ CHAVEZ
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 1:160 S 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-3211
Mailing Address - Country:US
Mailing Address - Phone:626-961-8971
Mailing Address - Fax:626-961-6685
Practice Address - Street 1:560 S ST LOUIS ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-4320
Practice Address - Country:US
Practice Address - Phone:213-480-1557
Practice Address - Fax:213-480-1182
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANONE2171M00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker