Provider Demographics
NPI:1376733915
Name:OTTER, KAYE BRADLEY (DC)
Entity Type:Individual
Prefix:DR
First Name:KAYE
Middle Name:BRADLEY
Last Name:OTTER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 PENN AVE S
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1360
Mailing Address - Country:US
Mailing Address - Phone:612-827-2651
Mailing Address - Fax:952-303-6528
Practice Address - Street 1:8100 PENN AVE S
Practice Address - Street 2:SUITE 103
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1360
Practice Address - Country:US
Practice Address - Phone:952-303-5182
Practice Address - Fax:952-303-6528
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN001763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN765327100Medicaid
MN350002829Medicare UPIN