MEDICARE: SHAVONDAH PORTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1437478609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAVONDAH PORTER

Provider Business Mailing Address
First Line	:	PO BOX 4919
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-0919
Country	:	US
Telephone Number	:	314-941-2705
Fax Number	:	314-769-9717

Provider Business Practice Location Address
First Line	:	6714 ETZEL AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63130-2427
Country	:	US
Telephone Number	:	314-941-2705
Fax Number	:	314-769-9717

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2010
Last Update Date	:	05/26/2010

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Directions to “ SHAVONDAH PORTER ” Practice Location

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