Provider Demographics
NPI:1073617502
Name:POTESTIVO, JAMES DANIEL (AT,C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DANIEL
Last Name:POTESTIVO
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 N HANSELMAN ST
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-1234
Mailing Address - Country:US
Mailing Address - Phone:989-269-2690
Mailing Address - Fax:
Practice Address - Street 1:6190 HOSPITAL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CASS CITY
Practice Address - State:MI
Practice Address - Zip Code:48726-1072
Practice Address - Country:US
Practice Address - Phone:989-872-2084
Practice Address - Fax:989-872-4337
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer