Provider Demographics
NPI:1912365388
Name:LOPEZ, RALPH
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:
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 1:7531 LOCH ALENE AVE
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-4133
Mailing Address - Country:US
Mailing Address - Phone:714-542-3581
Mailing Address - Fax:714-542-2246
Practice Address - Street 1:2101 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-4007
Practice Address - Country:US
Practice Address - Phone:714-542-3581
Practice Address - Fax:714-542-2246
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARII03270115171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC3854018Medicaid