Healthcare Provider Details

I. General information

NPI: 1063546422
Provider Name (Legal Business Name): MR. LEE A. OTIS III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 W ADAMS BLVD
LOS ANGELES CA
90018-1838
US

IV. Provider business mailing address

5717 SAN VICENTE BLVD
LOS ANGELES CA
90019-2525
US

V. Phone/Fax

Practice location:
  • Phone: 323-596-2480
  • Fax: 323-569-2487
Mailing address:
  • Phone: 323-633-4231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: