MEDICARE: JOSEPH ADAM POTESTA DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	3632	WV

General Provider Information

NPI Number	:	1578912812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH ADAM POTESTA DPT

Provider Business Mailing Address
First Line	:	1900 LOCUST AVE
Second Line	:	STE A
City	:	FAIRMONT
State	:	WV
Zip	:	26554-1293
Country	:	US
Telephone Number	:	304-986-9007
Fax Number	:	304-986-9080

Provider Business Practice Location Address
First Line	:	802 E MAIN ST
Second Line	:
City	:	MANNINGTON
State	:	WV
Zip	:	26582-1215
Country	:	US
Telephone Number	:	304-986-9007
Fax Number	:	304-986-9080

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2016
Last Update Date	:	11/22/2016

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