Provider Demographics
NPI:1336321587
Name:POTETTI'SBACK IN SHAPE CHIROPACTIC CENTER
Entity Type:Organization
Organization Name:POTETTI'SBACK IN SHAPE CHIROPACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:POTETTI
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:847-249-2225
Mailing Address - Street 1:5101 WASHINGTON ST
Mailing Address - Street 2:SUITE 2-I
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5916
Mailing Address - Country:US
Mailing Address - Phone:847-249-2225
Mailing Address - Fax:847-249-0078
Practice Address - Street 1:5101 WASHINGTON ST
Practice Address - Street 2:SUITE 2-I
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5916
Practice Address - Country:US
Practice Address - Phone:847-249-2225
Practice Address - Fax:847-249-0078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty