MEDICARE: SOTO EXECUTIVE ENTERPRISE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084F0202X	Forensic Psychiatry Physician

General Provider Information

NPI Number	:	1093303182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOTO EXECUTIVE ENTERPRISE, LLC

Provider Business Mailing Address
First Line	:	5227 SPRING BRANCH BLVD
Second Line	:
City	:	MONTCLAIR
State	:	VA
Zip	:	22025-3048
Country	:	US
Telephone Number	:	571-288-3440
Fax Number	:

Provider Business Practice Location Address
First Line	:	5227 SPRING BRANCH BLVD
Second Line	:
City	:	MONTCLAIR
State	:	VA
Zip	:	22025-3048
Country	:	US
Telephone Number	:	571-288-3440
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	MR. RAFAEL SOTO III
Credential	:
Telephone Number	:	571-288-3440

Provider Enumeration Date	:	01/05/2021
Last Update Date	:	01/05/2021

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