Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 1818 | MN |
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 1818 | MN |
NPI | 1598752859 |
---|---|
Provider Name | Dr. Richard Vincent Ottomeyer |
First Address | Forest Lake, MN 55025-8277 |
Second Address | Forest Lake, MN 55025-4401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2005 |
Last Update Date | 06/02/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
513527000 | (05) | MN |
T39815 | (02) | MN |