Healthcare Provider Details

I. General information

NPI: 1477784726
Provider Name (Legal Business Name): EILEEN L SMITH PORTER R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 STATE ST CARDIAC WELLNESS @ EMMC, 2 KAGAN BLDG
BANGOR ME
04401-6616
US

IV. Provider business mailing address

43 WHITING HILL RD SUITE 300
BREWER ME
04412-1005
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-7218
  • Fax:
Mailing address:
  • Phone: 207-973-5035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI260
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: