Healthcare Provider Details

I. General information

NPI: 1013192434
Provider Name (Legal Business Name): CHARLES HENRY SOTTORIVA D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 E SAINT LOUIS AVE
EAST ALTON IL
62024-1542
US

IV. Provider business mailing address

5414 HEEGE RD
SAINT LOUIS MO
63123-3504
US

V. Phone/Fax

Practice location:
  • Phone: 314-229-0441
  • Fax:
Mailing address:
  • Phone: 314-229-0441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: