MEDICARE: VITAELOLA 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	374J00000X	Doula

General Provider Information

NPI Number	:	1659187805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VITAELOLA PORTER

Provider Business Mailing Address
First Line	:	1038 W 122ND ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90044-2924
Country	:	US
Telephone Number	:	310-936-8638
Fax Number	:

Provider Business Practice Location Address
First Line	:	1038 W 122ND ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90044-2924
Country	:	US
Telephone Number	:	310-936-8638
Fax Number	:

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

Provider Enumeration Date	:	12/03/2024
Last Update Date	:	12/03/2024

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Directions to “ VITAELOLA PORTER ” Practice Location

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