Healthcare Provider Details

I. General information

NPI: 1790017176
Provider Name (Legal Business Name): MICHAEL JOHN PORTONOVA D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 NORTH CHURCH STREET
HAZLETON PA
18201
US

IV. Provider business mailing address

943 N CHURCH ST
HAZLETON PA
18201-1800
US

V. Phone/Fax

Practice location:
  • Phone: 570-401-1916
  • Fax:
Mailing address:
  • Phone: 570-861-8502
  • Fax: 570-861-8170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC 010381
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier12215846
Identifier TypeOTHER
Identifier State
Identifier IssuerCAQH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: