Provider Demographics
NPI:1962505263
Name:POTTHOFF, SANDRA JEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:JEAN
Last Name:POTTHOFF
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:SANDRA
Other - Middle Name:JEAN
Other - Last Name:TANKERSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:709 SEBASTIAN BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-8704
Mailing Address - Country:US
Mailing Address - Phone:772-219-4488
Mailing Address - Fax:772-872-5225
Practice Address - Street 1:709 SEBASTIAN BLVD STE F
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-8704
Practice Address - Country:US
Practice Address - Phone:772-663-2227
Practice Address - Fax:772-872-5225
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9896111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U54098Medicare UPIN
3973806Medicare ID - Type Unspecified