Healthcare Provider Details

I. General information

NPI: 1700214061
Provider Name (Legal Business Name): OTRA LEE OLVER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29050 S WESTERN AVE STE 153
RANCHO PALOS VERDES CA
90275-0821
US

IV. Provider business mailing address

501 E KATELLA AVE APT 4D
ORANGE CA
92867-4906
US

V. Phone/Fax

Practice location:
  • Phone: 310-519-8877
  • Fax:
Mailing address:
  • Phone: 408-202-9796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number32575
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: