Provider Demographics
NPI:1174052443
Name:POTTORFF, BYRON (MS, ATC)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:
Last Name:POTTORFF
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3156
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71272-0001
Mailing Address - Country:US
Mailing Address - Phone:318-265-4894
Mailing Address - Fax:
Practice Address - Street 1:1450 WEST ALABAMA
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71272
Practice Address - Country:US
Practice Address - Phone:318-265-4894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3036662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer