=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962932632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOTARA MANALO RICO PROFESSIONAL MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2017
-----------------------------------------------------
Last Update Date | 03/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5253 RIVERSIDE DR
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-4151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-464-2845
-----------------------------------------------------
Fax | 909-464-2848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 LAS LUNAS ST
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91106-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-457-1235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SOTARA MANALO RICO
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 909-464-2845
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------