Healthcare Provider Details

I. General information

NPI: 1760906085
Provider Name (Legal Business Name): ROBERTO SOTELO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 NORTH FAIR OAKS AVE.
PASADENA CA
91103
US

IV. Provider business mailing address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-6793
  • Fax:
Mailing address:
  • Phone: 626-798-6793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number691471
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: