Provider Demographics
NPI:1598542243
Name:POTTS, MARK TAVIN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TAVIN
Last Name:POTTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 E INDEPENDENCE BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-7034
Mailing Address - Country:US
Mailing Address - Phone:704-201-7944
Mailing Address - Fax:
Practice Address - Street 1:2925 E INDEPENDENCE BLVD STE 203
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7034
Practice Address - Country:US
Practice Address - Phone:704-201-7944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC7130251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health