Healthcare Provider Details

I. General information

NPI: 1154939346
Provider Name (Legal Business Name): TARA GRACE PORTER ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 8TH ST
WEST PLAINS MO
65775-2010
US

IV. Provider business mailing address

1480 8TH ST
WEST PLAINS MO
65775-2010
US

V. Phone/Fax

Practice location:
  • Phone: 417-926-5699
  • Fax:
Mailing address:
  • Phone: 417-926-5699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT1533
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2020021125
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: