Provider Demographics
NPI:1619165875
Name:OTTO CHIROPRACTIC, S.C.
Entity Type:Organization
Organization Name:OTTO CHIROPRACTIC, S.C.
Other - Org Name:OTTO CHIROPRACTIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CO-OWNER, AO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-915-6802
Mailing Address - Street 1:308 E NORTHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-2163
Mailing Address - Country:US
Mailing Address - Phone:920-739-6800
Mailing Address - Fax:920-739-3999
Practice Address - Street 1:308 E NORTHLAND AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-2163
Practice Address - Country:US
Practice Address - Phone:920-739-6800
Practice Address - Fax:920-739-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3082-012111N00000X, 111N00000X
WI4345-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38976800Medicaid