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General NPI Number Information
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NPI Number | 1053988394
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Entity Type | Individual
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Provider Name | MAKAYLA JO PORTER OD
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Gender | Female
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Dates
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Enumeration Date | 06/07/2021
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Last Update Date | 06/07/2021
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Provider Practice Location Address
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Address Line | 4763 WILSON AVE SW STE G&H
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City | GRANDVILLE
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State | MI
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Zip | 49418-9015
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Country | US
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Telephone | 616-261-4811
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Fax |
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Provider Business Mailing Address
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Address Line | 2056 MORGAN RUN
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City | HUDSONVILLE
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State | MI
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Zip | 49426
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Country | US
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Telephone | 812-240-9888
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901005517
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License Number State | MI
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