MEDICARE: SOPHUS GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1659750859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOPHUS GROUP INC

Provider Business Mailing Address
First Line	:	5240 SAN FERNANDO ROAD SUITE B7
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91203
Country	:	US
Telephone Number	:	818-638-3113
Fax Number	:

Provider Business Practice Location Address
First Line	:	5240 SAN FERNANDO RD STE B7
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91203-2439
Country	:	US
Telephone Number	:	818-638-3113
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. STEPHEN COBOS
Credential	:
Telephone Number	:	818-638-3113

Provider Enumeration Date	:	05/21/2015
Last Update Date	:	05/21/2015

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