Provider Demographics
NPI:1558588905
Name:OTTER & TROUT TRADING CO INC
Entity Type:Organization
Organization Name:OTTER & TROUT TRADING CO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO (MASSAGE THERAPIST)
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLI
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE OTTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, ACST, NCTMB
Authorized Official - Phone:352-485-3599
Mailing Address - Street 1:1623 NW 156TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-4057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1135 NW 23RD AVE STE F
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-3449
Practice Address - Country:US
Practice Address - Phone:352-514-2375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA29294225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA29294OtherMASSAGE THERAPY LICENSE
FLC2044OtherBLUE CROSS PROVIDER #