MEDICARE: DR. JEREL KENNETH WOTTRICH SR. D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC2911	TX

General Provider Information

NPI Number	:	1679667349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREL KENNETH WOTTRICH SR. D.C.

Provider Business Mailing Address
First Line	:	2121 E OLTORF SUITE 2
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78741
Country	:	US
Telephone Number	:	512-448-1012
Fax Number	:	512-448-2706

Provider Business Practice Location Address
First Line	:	2121 E OLTORF SUITE 2
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78741
Country	:	US
Telephone Number	:	512-448-1012
Fax Number	:	512-448-2706

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/08/2007

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