Provider Demographics
NPI:1063546422
Name:OTIS, LEE A III
Entity type:Individual
Prefix:MR
First Name:LEE
Middle Name:A
Last Name:OTIS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 SAN VICENTE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-2525
Mailing Address - Country:US
Mailing Address - Phone:323-633-4231
Mailing Address - Fax:
Practice Address - Street 1:3320 W ADAMS BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-1838
Practice Address - Country:US
Practice Address - Phone:323-596-2480
Practice Address - Fax:323-569-2487
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner