=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457972283
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENTUCKY ACCIDENT & INJURY CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2020
-----------------------------------------------------
Last Update Date | 05/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 NORTH HWY 27
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42503-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-667-0101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 718 LAKE DRIVE LN
-----------------------------------------------------
City | LA FOLLETTE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37766-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-230-1185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | DR. LARRY L OTEHAM
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 606-667-0101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------