Provider Demographics
NPI:1861170052
Name:LOPEZ, ANTONIO BENJAMIN
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:BENJAMIN
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 1:1455 ALTURAS RD SPC 37
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-3925
Mailing Address - Country:US
Mailing Address - Phone:760-696-1868
Mailing Address - Fax:
Practice Address - Street 1:1455 ALTURAS RD SPC 37
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3925
Practice Address - Country:US
Practice Address - Phone:760-696-1868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst