1407946700 NPI number — VICKIE LYNN POTTER M.S., L.P.

Table of content: VICKIE LYNN POTTER M.S., L.P. (NPI 1407946700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407946700 NPI number — VICKIE LYNN POTTER M.S., L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTTER
Provider First Name:
VICKIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., L.P.
Provider Gender Code:
F

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:
1407946700
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:
97 PLEASANT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANITE FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56241-9470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-564-2488
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
290 9TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANITE FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56241-1439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-564-5670
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2006

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: 103T00000X , with the licence number:  2895 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2897227 . This is a "TAX NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: L.P 2895 . This is a "L.P. NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 114832 . This is a "U CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 9H516PO . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P51552 . This is a "ARAZ CODE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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