Provider Demographics
NPI:1770663155
Name:LOPEZ, NICOLE MARIE (DC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 MAJESTIC CT
Mailing Address - Street 2:# 103
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-2175
Mailing Address - Country:US
Mailing Address - Phone:805-490-5489
Mailing Address - Fax:805-482-0205
Practice Address - Street 1:266 MOBIL AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6328
Practice Address - Country:US
Practice Address - Phone:805-482-0105
Practice Address - Fax:805-482-0205
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28513111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6008635Medicaid
CAW16696Medicare ID - Type Unspecified