Provider Demographics
NPI:1962997718
Name:LOPEZ, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 EVERGREEN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-7035
Mailing Address - Country:US
Mailing Address - Phone:323-453-3800
Mailing Address - Fax:
Practice Address - Street 1:5350 MACHADO RD.
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230
Practice Address - Country:US
Practice Address - Phone:310-737-9393
Practice Address - Fax:310-881-0069
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2023-12-21
Deactivation Date:2022-08-03
Deactivation Code:
Reactivation Date:2023-12-21
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker