Healthcare Provider Details

I. General information

NPI: 1487586053
Provider Name (Legal Business Name): DAMETRIS ABELARDO PORRAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2026
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5115 DUDLEY BLVD
MCCLELLAN CA
95652-1024
US

IV. Provider business mailing address

1360 LAKESIDE AVE APT 143
MANTECA CA
95337-2218
US

V. Phone/Fax

Practice location:
  • Phone: 209-912-9056
  • Fax:
Mailing address:
  • Phone: 209-912-9056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: