Provider Demographics
NPI:1154446417
Name:POTOCKI, THADDEUS J (DC)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:J
Last Name:POTOCKI
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 1:5150 SUNRISE BLVD
Mailing Address - Street 2:SUITE F1
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-4939
Mailing Address - Country:US
Mailing Address - Phone:916-536-0400
Mailing Address - Fax:916-344-8523
Practice Address - Street 1:5150 SUNRISE BLVD
Practice Address - Street 2:SUITE F1
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-4939
Practice Address - Country:US
Practice Address - Phone:916-536-0400
Practice Address - Fax:916-344-8523
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC020349111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0203490Medicare UPIN