Provider Demographics
NPI:1649262254
Name:POTTER, ROBERT EDWARD JR (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:POTTER
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6231 N CANTON CENTER RD
Mailing Address - Street 2:STE 109
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2694
Mailing Address - Country:US
Mailing Address - Phone:734-455-6767
Mailing Address - Fax:734-455-2359
Practice Address - Street 1:6231 N CANTON CENTER RD
Practice Address - Street 2:STE 109
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2694
Practice Address - Country:US
Practice Address - Phone:734-455-6767
Practice Address - Fax:734-455-2359
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005410111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM85750001Medicare ID - Type Unspecified
U23027Medicare UPIN