=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619970910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROACTIVE IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2005
-----------------------------------------------------
Last Update Date | 10/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 W 76TH ST STE 100
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-5104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-853-7226
-----------------------------------------------------
Fax | 952-831-7555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 W 76TH ST STE 100
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-5104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-853-7226
-----------------------------------------------------
Fax | 952-831-7555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ANGEL L SOTO
-----------------------------------------------------
Credential | PRESIDENT
-----------------------------------------------------
Telephone | 954-559-2421
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 540
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------