Provider Demographics
NPI:1548926595
Name:OTERO, ALEC MATEO (DPT)
Entity type:Individual
Prefix:
First Name:ALEC
Middle Name:MATEO
Last Name:OTERO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1505
Mailing Address - Country:US
Mailing Address - Phone:270-404-5440
Mailing Address - Fax:
Practice Address - Street 1:5796 NASHVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-7546
Practice Address - Country:US
Practice Address - Phone:270-745-0987
Practice Address - Fax:270-745-0986
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008435225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0037133761Medicaid