Healthcare Provider Details

I. General information

NPI: 1417108473
Provider Name (Legal Business Name): PORTER PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6191 PORTER RD
GRAND BLANC MI
48439-8540
US

IV. Provider business mailing address

6191 PORTER RD
GRAND BLANC MI
48439-8540
US

V. Phone/Fax

Practice location:
  • Phone: 810-603-1393
  • Fax: 810-603-1394
Mailing address:
  • Phone: 810-603-1393
  • Fax: 810-603-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License NumberAF250088873
License Number StateMI

VIII. Authorized Official

Name: DANIEL S. BURNETT
Title or Position: MANAGER
Credential:
Phone: 810-603-1393