Healthcare Provider Details

I. General information

NPI: 1164269064
Provider Name (Legal Business Name): MARYNDA UNIQUIAH PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 N THOMAS RD APT 101E
TALLMADGE OH
44278-1737
US

IV. Provider business mailing address

265 N THOMAS RD APT 101E
TALLMADGE OH
44278-1737
US

V. Phone/Fax

Practice location:
  • Phone: 330-540-3757
  • Fax:
Mailing address:
  • Phone: 330-540-3757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: