Provider Demographics
NPI:1578848701
Name:POTOCKI FAMILY CHIROPRACTIC AND LASER CENTER INC
Entity Type:Organization
Organization Name:POTOCKI FAMILY CHIROPRACTIC AND LASER CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THADDEUS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:POTOCKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:916-536-0400
Mailing Address - Street 1:5150 SUNRISE BLVD.
Mailing Address - Street 2:STE. 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:916-536-9039
Practice Address - Street 1:5150 SUNRISE BLVD
Practice Address - Street 2:STE. 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:916-536-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC020349111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0203490Medicare PIN