Healthcare Provider Details

I. General information

NPI: 1679578280
Provider Name (Legal Business Name): WILLIAM J OTTERSBERG JR. D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 E HWY 50 SUITE C
CANON CITY CO
81212-2775
US

IV. Provider business mailing address

3055 E HWY 50 SUITE C
CANON CITY CO
81212-2775
US

V. Phone/Fax

Practice location:
  • Phone: 719-269-1020
  • Fax: 719-269-1021
Mailing address:
  • Phone: 719-269-1020
  • Fax: 719-269-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2420
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: