Healthcare Provider Details

I. General information

NPI: 1154571180
Provider Name (Legal Business Name): PORTER HOSPITAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 WILLOWCREEK RD
PORTAGE IN
46368-5075
US

IV. Provider business mailing address

814 LAPORTE AVE
VALPARAISO IN
46383-5860
US

V. Phone/Fax

Practice location:
  • Phone: 219-263-4600
  • Fax:
Mailing address:
  • Phone: 219-263-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number07-0050331
License Number StateIN

VIII. Authorized Official

Name: PUALA M LALOR
Title or Position: DIRECTOR/DELEGATED OFFICIAL
Credential:
Phone: 629-215-3953