Basic Information
| Provider Information | |||||||||
| NPI: | 1427697945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SORETA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DELA VEGA | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 156 CASTLEKNOCK RD | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252131117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047515458 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 ASSOCIATION DR | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253111272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043436600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2019 | ||||||||
| LastUpdateDate: | 12/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/31/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT002818 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.