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General NPI Number Information
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NPI Number | 1326521618
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Entity Type | Individual
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Provider Name | GREGORY ALEXANDER PORTER PTA
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Gender | Male
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Dates
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Enumeration Date | 09/12/2018
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Last Update Date | 09/12/2018
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Provider Practice Location Address
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Address Line | 44656 MOUND RD
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City | STERLING HEIGHTS
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State | MI
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Zip | 48314-1322
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Country | US
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Telephone | 586-884-4565
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Fax | 888-996-2534
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Provider Business Mailing Address
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Address Line | 230 PAULINE PASS
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City | LINDEN
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State | MI
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Zip | 48451-9674
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Country | US
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Telephone | 810-955-6201
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 5502005702
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License Number State | MI
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