Healthcare Provider Details

I. General information

NPI: 1568165629
Provider Name (Legal Business Name): MONTEZ PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 N 36TH ST
MILWAUKEE WI
53210-1925
US

IV. Provider business mailing address

2823 N 36TH ST
MILWAUKEE WI
53210-1925
US

V. Phone/Fax

Practice location:
  • Phone: 414-231-0644
  • Fax:
Mailing address:
  • Phone: 414-231-0644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: