Provider Demographics
NPI:1548738081
Name:SOTELO, SALVADOR
Entity Type:Individual
Prefix:
First Name:SALVADOR
Middle Name:
Last Name:SOTELO
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:PO BOX 720959
Mailing Address - Street 2:
Mailing Address - City:PINON HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92372-0959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11167 WAGON TRAIN RD
Practice Address - Street 2:
Practice Address - City:PHELAN
Practice Address - State:CA
Practice Address - Zip Code:92371-8166
Practice Address - Country:US
Practice Address - Phone:949-310-7596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst