Healthcare Provider Details

I. General information

NPI: 1114919016
Provider Name (Legal Business Name): ROBERT EDWARD POTTER JR DC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6231 N CANTON CENTER RD SUITE 109
CANTON MI
48187-2694
US

IV. Provider business mailing address

6231 N CANTON CENTER RD SUITE 109
CANTON MI
48187-2694
US

V. Phone/Fax

Practice location:
  • Phone: 734-455-6767
  • Fax: 734-455-2359
Mailing address:
  • Phone: 734-455-6767
  • Fax: 734-455-2359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301005410
License Number StateMI

VIII. Authorized Official

Name: ROBERT EDWARD POTTER JR.
Title or Position: OWNER
Credential: DC
Phone: 734-455-6767