Healthcare Provider Details

I. General information

NPI: 1346914942
Provider Name (Legal Business Name): KYLE PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 BUCKMAN SPRINGS RD
CAMPO CA
91906-2022
US

IV. Provider business mailing address

16782 VON KARMAN AVE STE 11
IRVINE CA
92606-2417
US

V. Phone/Fax

Practice location:
  • Phone: 619-478-5696
  • Fax:
Mailing address:
  • Phone: 855-223-7123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1452760826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: