Healthcare Provider Details

I. General information

NPI: 1174052443
Provider Name (Legal Business Name): BYRON POTTORFF MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 WEST ALABAMA
RUSTON LA
71272
US

IV. Provider business mailing address

PO BOX 3156
RUSTON LA
71272-0001
US

V. Phone/Fax

Practice location:
  • Phone: 318-265-4894
  • Fax:
Mailing address:
  • Phone: 318-265-4894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number303666
License Number StateLA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: