Provider Demographics
NPI:1114120649
Name:FRONTIER INTEGRATED HEALTH CENTER INC
Entity Type:Organization
Organization Name:FRONTIER INTEGRATED HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:OTTOMEYER
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:636-379-5934
Mailing Address - Street 1:199 FRONTIER PARK DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3963
Mailing Address - Country:US
Mailing Address - Phone:636-379-5934
Mailing Address - Fax:636-410-3323
Practice Address - Street 1:199 FRONTIER PARK DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3963
Practice Address - Country:US
Practice Address - Phone:636-379-5934
Practice Address - Fax:636-410-3323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 207Q00000X
MO112431261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO160876OtherBLUECROSS
MO2576722OtherUNITED HEALTHCARE
MO375245OtherHEALTHLINK
MO2576722OtherUNITED HEALTHCARE