Provider Demographics
NPI:1942722947
Name:POTRZEBOWSKI, SAMANTHA (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:POTRZEBOWSKI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12040 ETRIS RD STE D120
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-8016
Mailing Address - Country:US
Mailing Address - Phone:770-645-1880
Mailing Address - Fax:
Practice Address - Street 1:12040 ETRIS RD STE D120
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-8016
Practice Address - Country:US
Practice Address - Phone:770-645-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009306111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACHIR009306OtherCHIROPRACTIC LICENSE