Healthcare Provider Details

I. General information

NPI: 1316960404
Provider Name (Legal Business Name): KENNETH K POTTS C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 EAST 12TH STREET
MENDOTA IL
61342-9216
US

IV. Provider business mailing address

1401 EAST 12TH STREET
MENDOTA IL
61342-9216
US

V. Phone/Fax

Practice location:
  • Phone: 815-539-7461
  • Fax: 815-539-1461
Mailing address:
  • Phone: 815-539-7461
  • Fax: 815-539-1461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041136641
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: