Provider Demographics
NPI:1679725386
Name:OTT CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:OTT CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:262-695-9698
Mailing Address - Street 1:601 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-1844
Mailing Address - Country:US
Mailing Address - Phone:262-695-9698
Mailing Address - Fax:262-695-0144
Practice Address - Street 1:601 RYAN ST
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-1844
Practice Address - Country:US
Practice Address - Phone:262-695-9698
Practice Address - Fax:262-695-0144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3063111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38881500Medicaid
WI0000070728OtherMEDICARE ID
WI38881500Medicaid