MEDICARE: AMANDA LEE PORTER DC

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	111N00000X	Chiropractor	CH11475	FL

General Provider Information

NPI Number	:	1831574110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA LEE PORTER DC

Provider Business Mailing Address
First Line	:	6947 MERRILL RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32277-2684
Country	:	US
Telephone Number	:	904-743-2222
Fax Number	:	904-743-3087

Provider Business Practice Location Address
First Line	:	2160 DUNN AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-4718
Country	:	US
Telephone Number	:	904-743-2222
Fax Number	:	904-743-3087

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

Provider Enumeration Date	:	07/28/2015
Last Update Date	:	07/28/2015

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