Provider Demographics
NPI:1780712711
Name:POTETTI, LEO JOSEPH JR (DC)
Entity type:Individual
Prefix:DR
First Name:LEO
Middle Name:JOSEPH
Last Name:POTETTI
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:5101 WASHINGTON ST
Mailing Address - Street 2:SUITE 2-I
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5916
Mailing Address - Country:US
Mailing Address - Phone:847-249-2225
Mailing Address - Fax:847-249-0078
Practice Address - Street 1:5101 WASHINGTON ST
Practice Address - Street 2:SUITE 2-I
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5916
Practice Address - Country:US
Practice Address - Phone:847-249-2225
Practice Address - Fax:847-249-0078
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01618444Medicare UPIN