Healthcare Provider Details

I. General information

NPI: 1306194261
Provider Name (Legal Business Name): SOEPRONO MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 TERRACINA BLVD STE 206
REDLANDS CA
92373-4870
US

IV. Provider business mailing address

PO BOX 1180
LOMA LINDA CA
92354-1180
US

V. Phone/Fax

Practice location:
  • Phone: 909-792-8600
  • Fax: 909-792-8660
Mailing address:
  • Phone: 909-792-8600
  • Fax: 909-792-8660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberG28216
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number005D0573825
License Number StateCA

VIII. Authorized Official

Name: DR. FRED F SOEPRONO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-203-5000