Provider Demographics
NPI:1104007400
Name:POTTER, GARY LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:POTTER
Suffix:
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 1:1322 3RD ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-2101
Mailing Address - Country:US
Mailing Address - Phone:218-283-2243
Mailing Address - Fax:
Practice Address - Street 1:1322 3RD ST
Practice Address - Street 2:SUITE 4
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-2101
Practice Address - Country:US
Practice Address - Phone:218-283-2243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2740111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor