MEDICARE: NATALIE SYLVIA OTOYA STUDENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	4297	NC
2	111N00000X	Chiropractor	3701	SC
3	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1043458557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATALIE SYLVIA OTOYA STUDENT

Provider Business Mailing Address
First Line	:	2327 SHENANDOAH AVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-6025
Country	:	US
Telephone Number	:	703-593-1906
Fax Number	:

Provider Business Practice Location Address
First Line	:	2327 SHENANDOAH AVE.
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205
Country	:	US
Telephone Number	:	703-593-1906
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2009
Last Update Date	:	07/24/2015

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