Healthcare Provider Details

I. General information

NPI: 1407079312
Provider Name (Legal Business Name): DR. KAYE B. OTTER,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 PENN AVE S STE 103
BLOOMINGTON MN
55431-1360
US

IV. Provider business mailing address

8100 PENN AVE S STE 103
BLOOMINGTON MN
55431-1360
US

V. Phone/Fax

Practice location:
  • Phone: 952-303-5182
  • Fax: 952-303-5182
Mailing address:
  • Phone: 952-303-5182
  • Fax: 952-303-5182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number1763
License Number StateMN

VIII. Authorized Official

Name: DR. KAYE BRADLEY OTTER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 612-827-2651