Healthcare Provider Details

I. General information

NPI: 1710167218
Provider Name (Legal Business Name): CASEY MARK PORTNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 NE 13TH ST
FORT LAUDERDALE FL
33304-2009
US

IV. Provider business mailing address

919 NE 13TH ST
FORT LAUDERDALE FL
33304-2009
US

V. Phone/Fax

Practice location:
  • Phone: 954-763-2030
  • Fax: 954-467-5844
Mailing address:
  • Phone: 954-763-2030
  • Fax: 954-467-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: