MEDICARE: DAKOTA PORTER PT, DPT

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	225100000X	Physical Therapist	12320	SC

General Provider Information

NPI Number	:	1710735485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAKOTA PORTER PT, DPT

Provider Business Mailing Address
First Line	:	201 SMYTHE ST APT 234
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29611-6347
Country	:	US
Telephone Number	:	407-820-6695
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 HAMPTON AVENUE EXT STE 11B
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29601-1168
Country	:	US
Telephone Number	:	864-900-2975
Fax Number	:

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

Provider Enumeration Date	:	05/08/2024
Last Update Date	:	05/13/2024

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