Provider Demographics
NPI:1497813083
Name:OTTO, LEROY FRANK (DC)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:FRANK
Last Name:OTTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 SOUTH HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-1637
Mailing Address - Country:US
Mailing Address - Phone:651-345-3361
Mailing Address - Fax:651-345-4049
Practice Address - Street 1:127 SOUTH HIGH STREET
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1637
Practice Address - Country:US
Practice Address - Phone:651-345-3361
Practice Address - Fax:651-345-4049
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1417111N00000X
WI1381111N00000X
MT857CHI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
36065OTOtherBCBS
36065OTOtherBCBS