=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306194261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOEPRONO MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2012
-----------------------------------------------------
Last Update Date | 09/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 TERRACINA BLVD STE 206
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-4870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-792-8600
-----------------------------------------------------
Fax | 909-792-8660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1180
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-1180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-792-8600
-----------------------------------------------------
Fax | 909-792-8660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. FRED F SOEPRONO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 951-203-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 005D0573825
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number | G28216
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------