1386791903 NPI number — MR. JEFFERY LYNN POTTHOFF ATC, LAT, CST

Table of content: MR. JEFFERY LYNN POTTHOFF ATC, LAT, CST (NPI 1386791903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386791903 NPI number — MR. JEFFERY LYNN POTTHOFF ATC, LAT, CST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTTHOFF
Provider First Name:
JEFFERY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC, LAT, CST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386791903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 SPRINGWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADKINS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78101-2711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-217-4472
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 MADISON OAK DR
Provider Second Line Business Practice Location Address:
SUITE 690
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78258-3943
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-491-3434
Provider Business Practice Location Address Fax Number:
210-496-7746
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  AT0624 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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