Provider Demographics
NPI:1114919016
Name:ROBERT EDWARD POTTER JR DC PLLC
Entity Type:Organization
Organization Name:ROBERT EDWARD POTTER JR DC PLLC
Other - Org Name:CANTON CENTER CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:734-455-6767
Mailing Address - Street 1:6231 N CANTON CENTER RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2694
Mailing Address - Country:US
Mailing Address - Phone:734-455-6767
Mailing Address - Fax:734-455-2359
Practice Address - Street 1:6231 N CANTON CENTER RD
Practice Address - Street 2:SUITE 109
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2694
Practice Address - Country:US
Practice Address - Phone:734-455-6767
Practice Address - Fax:734-455-2359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005410111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U23027Medicare UPIN
MI0M85750Medicare ID - Type Unspecified