=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508152661
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIK ROBERT OTTO L.M.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2011
-----------------------------------------------------
Last Update Date | 06/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10054 DELICATE DEW ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89183-7139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-762-8774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10054 DELICATE DEW ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89183-7139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-762-8774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | NVMT.5243
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------