Healthcare Provider Details

I. General information

NPI: 1063118867
Provider Name (Legal Business Name): JEREMY SOTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1768 MITCHELL RD STE 301
CERES CA
95307-2156
US

IV. Provider business mailing address

584 E BELLEVUE RD
ATWATER CA
95301-2300
US

V. Phone/Fax

Practice location:
  • Phone: 209-353-4838
  • Fax:
Mailing address:
  • Phone: 559-747-2177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: