Healthcare Provider Details

I. General information

NPI: 1316332315
Provider Name (Legal Business Name): ERIC PORT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5959 INDEPENDENCE AVE
BRONX NY
10471-1222
US

IV. Provider business mailing address

5959 INDEPENDENCE AVE
BRONX NY
10471-1222
US

V. Phone/Fax

Practice location:
  • Phone: 718-796-4200
  • Fax: 718-874-9871
Mailing address:
  • Phone: 718-796-4200
  • Fax: 718-874-9871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374T00000X
TaxonomyReligious Nonmedical Nursing Personnel
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: