MEDICARE: CHARLES FREDRICK 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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1699467175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES FREDRICK PORTER

Provider Business Mailing Address
First Line	:	8232 OCEAN TERRACE WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-7457
Country	:	US
Telephone Number	:	602-400-0231
Fax Number	:

Provider Business Practice Location Address
First Line	:	4480 W PEORIA AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85302-2038
Country	:	US
Telephone Number	:	702-807-8670
Fax Number	:

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

Provider Enumeration Date	:	05/23/2023
Last Update Date	:	05/23/2023

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Directions to “ CHARLES FREDRICK PORTER ” Practice Location

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