Healthcare Provider Details

I. General information

NPI: 1467947879
Provider Name (Legal Business Name): MR. DYLAN OTTEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 GOVERNORS LN
CHICO CA
95926-1991
US

IV. Provider business mailing address

9 GOVERNORS LN
CHICO CA
95926-1991
US

V. Phone/Fax

Practice location:
  • Phone: 530-894-6913
  • Fax: 530-894-6915
Mailing address:
  • Phone: 530-894-6913
  • Fax: 530-894-6915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberC52965
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: