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
StateLicense IDTaxonomies
MN5154111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty