Healthcare Provider Details

I. General information

NPI: 1932560778
Provider Name (Legal Business Name): AMARIS PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 BALLARD ST SE
GRAND RAPIDS MI
49507-2265
US

IV. Provider business mailing address

1245 BALLARD ST SE
GRAND RAPIDS MI
49507-2265
US

V. Phone/Fax

Practice location:
  • Phone: 616-819-0624
  • Fax:
Mailing address:
  • Phone: 616-819-0624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: