Healthcare Provider Details

I. General information

NPI: 1427697945
Provider Name (Legal Business Name): JOHN DELA VEGA SORETA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ASSOCIATION DR
CHARLESTON WV
25311-1272
US

IV. Provider business mailing address

156 CASTLEKNOCK RD
WINFIELD WV
25213-1117
US

V. Phone/Fax

Practice location:
  • Phone: 304-343-6600
  • Fax:
Mailing address:
  • Phone: 304-751-5458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT002818
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: