Provider Demographics
NPI:1861040958
Name:POTTS, REGINALD AVERY SR
Entity Type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:AVERY
Last Name:POTTS
Suffix:SR
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 1:760 MOUNTAIN VIEW ST
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-4996
Mailing Address - Country:US
Mailing Address - Phone:800-696-6793
Mailing Address - Fax:
Practice Address - Street 1:867 N FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-3050
Practice Address - Country:US
Practice Address - Phone:800-696-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-31
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner