Basic Information
| Provider Information | |||||||||
| NPI: | 1881938314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | CLYDE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 148 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | TRUSSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351731461 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 420 DEAN DR | ||||||||
| Address2: | |||||||||
| City: | GARDENDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350712763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056318709 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2012 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 151 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.