Provider Demographics
NPI:1124505466
Name:SOTO, ROBERTO ALEJANDRO
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:ALEJANDRO
Last Name:SOTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3406
Mailing Address - Country:US
Mailing Address - Phone:626-463-1021
Mailing Address - Fax:
Practice Address - Street 1:11731 TELEGRAPH RD STE K
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-6815
Practice Address - Country:US
Practice Address - Phone:626-701-9620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner