Healthcare Provider Details

I. General information

NPI: 1841546520
Provider Name (Legal Business Name): SUSAN CAROLE PORTER MT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 SIXTH AV N
WOLF POINT MT
59201-0729
US

IV. Provider business mailing address

550 6TH AVE NORTH
WOLF POINT MT
59201
US

V. Phone/Fax

Practice location:
  • Phone: 406-653-5628
  • Fax: 406-653-1177
Mailing address:
  • Phone: 406-653-5628
  • Fax: 406-653-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number805
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: