Provider Demographics
NPI:1891296117
Name:POTTS, MCKENZIE (LAT, ATC)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:POTTS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 S 800 W BSMT
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-6053
Mailing Address - Country:US
Mailing Address - Phone:937-751-2851
Mailing Address - Fax:
Practice Address - Street 1:665 W CENTER ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-5340
Practice Address - Country:US
Practice Address - Phone:937-751-2851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10071588-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer