Provider Demographics
NPI:1538407663
Name:POTTS, TIMOTHY VAN DYKE (LAC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:VAN DYKE
Last Name:POTTS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:TEO
Other - Middle Name:VAN DYKE
Other - Last Name:POTTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:1240 POWELL ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2600
Mailing Address - Country:US
Mailing Address - Phone:510-725-8791
Mailing Address - Fax:866-268-1114
Practice Address - Street 1:1240 POWELL ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2600
Practice Address - Country:US
Practice Address - Phone:510-725-8791
Practice Address - Fax:866-268-1114
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10892171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist