Provider Demographics
NPI:1972643765
Name:SOTONN, VIRAK (DC)
Entity Type:Individual
Prefix:DR
First Name:VIRAK
Middle Name:
Last Name:SOTONN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9217 17TH AVE S
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-2373
Mailing Address - Country:US
Mailing Address - Phone:952-881-0767
Mailing Address - Fax:952-881-0806
Practice Address - Street 1:9217 17TH AVE S
Practice Address - Street 2:SUITE 120
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-2373
Practice Address - Country:US
Practice Address - Phone:952-881-0767
Practice Address - Fax:952-881-0806
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4264111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN83G93APOtherBCBS CONTRACTING PROVIDER
MN83G52SOOtherBCBS INDIVIDUAL PROVIDER
MN83G52SOOtherBCBS INDIVIDUAL PROVIDER