Healthcare Provider Details

I. General information

NPI: 1891962635
Provider Name (Legal Business Name): SOTTORIVA CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 05/12/2008
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

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

V. Phone/Fax

Practice location:
  • Phone: 618-259-8000
  • Fax: 618-259-9808
Mailing address:
  • Phone: 618-259-8000
  • Fax: 618-259-9808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-011024
License Number StateIL

VIII. Authorized Official

Name: DR. CHARLES HENRY SOTTORIVA
Title or Position: PRESIDENT
Credential: DC
Phone: 618-259-8000