Healthcare Provider Details

I. General information

NPI: 1891060141
Provider Name (Legal Business Name): REBECCA RENEE POTTER D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

659 CHERRY ST STE. 201
SANTA ROSA CA
95404-4280
US

IV. Provider business mailing address

4272 WALLACE RD
SANTA ROSA CA
95404-1423
US

V. Phone/Fax

Practice location:
  • Phone: 707-570-2501
  • Fax:
Mailing address:
  • Phone: 707-570-2501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC25891
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: