Provider Demographics
NPI: | 1033348875 |
---|---|
Name: | POTENTIAL HEALTH PA |
Entity type: | Organization |
Organization Name: | POTENTIAL HEALTH PA |
Other - Org Name: | <UNAVAIL> |
Other - Org Type: | |
Authorized Official - Title/Position: | DOCTOR OF CHIROPRACTIC |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | RANDY |
Authorized Official - Middle Name: | JOHN |
Authorized Official - Last Name: | MAGES |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 507-387-5978 |
Mailing Address - Street 1: | 309 MADISON AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | MANKATO |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 56001-3310 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 507-387-5978 |
Mailing Address - Fax: | 507-387-2563 |
Practice Address - Street 1: | 309 MADISON AVE |
Practice Address - Street 2: | |
Practice Address - City: | MANKATO |
Practice Address - State: | MN |
Practice Address - Zip Code: | 56001-3310 |
Practice Address - Country: | US |
Practice Address - Phone: | 507-387-5978 |
Practice Address - Fax: | 507-387-2563 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-07-14 |
Last Update Date: | 2009-07-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 5154 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Single Specialty |