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General NPI Number Information
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NPI Number | 1013103225
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Entity Type | Organization
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Legal Business Name | OTTO CHIROPRACTIC CLINIC, S.C.
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Dates
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Enumeration Date | 09/20/2007
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Last Update Date | 09/20/2007
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Provider Practice Location Address
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Address Line | 1039 W MASON ST
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City | GREEN BAY
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State | WI
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Zip | 54303-1842
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Country | US
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Telephone | 920-965-7757
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Fax | 920-739-3999
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Provider Business Mailing Address
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Address Line | 1039 W MASON ST
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City | GREEN BAY
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State | WI
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Zip | 54303-1842
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Country | US
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Telephone | 920-965-7757
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Fax | 920-739-3999
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Authorized Official
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Title or Position | OWNER/ PRESIDENT/DOCTOR
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Name | DR. ANTHONY JAMES OTTO
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Credential | D.C.
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Telephone | 920-965-7757
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 12-4315
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License Number State | WI
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