Healthcare Provider Details

I. General information

NPI: 1790998995
Provider Name (Legal Business Name): EULA PORTER SST II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 COMER AVE
COLUMBUS GA
31904-8725
US

IV. Provider business mailing address

5629 LEXINGTON DR
COLUMBUS GA
31907-6738
US

V. Phone/Fax

Practice location:
  • Phone: 706-324-7074
  • Fax: 706-632-4703
Mailing address:
  • Phone: 706-685-2079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: