Provider Demographics
NPI:1962932632
Name:SOTARA MANALO RICO PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:SOTARA MANALO RICO PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOTARA
Authorized Official - Middle Name:MANALO
Authorized Official - Last Name:RICO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-464-2845
Mailing Address - Street 1:1601 LAS LUNAS ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-1302
Mailing Address - Country:US
Mailing Address - Phone:925-457-1235
Mailing Address - Fax:
Practice Address - Street 1:5253 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4151
Practice Address - Country:US
Practice Address - Phone:909-464-2845
Practice Address - Fax:909-464-2848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty