MEDICARE: MR. RICHARD PORTER JR.

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	CSAC-21997	NC

General Provider Information

NPI Number	:	1538533666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD PORTER JR.

Provider Business Mailing Address
First Line	:	142 SOUND DR
Second Line	:
City	:	ATLANTIC BEACH
State	:	NC
Zip	:	28512-5205
Country	:	US
Telephone Number	:	252-269-0199
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 ARENDELL ST
Second Line	:	#4
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-6511
Country	:	US
Telephone Number	:	252-269-0199
Fax Number	:

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

Provider Enumeration Date	:	12/01/2015
Last Update Date	:	12/01/2015

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