MEDICARE: AMARIS 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	247200000X	Other Technician

General Provider Information

NPI Number	:	1932560778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMARIS PORTER

Provider Business Mailing Address
First Line	:	1245 BALLARD ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-2265
Country	:	US
Telephone Number	:	616-819-0624
Fax Number	:

Provider Business Practice Location Address
First Line	:	1245 BALLARD ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-2265
Country	:	US
Telephone Number	:	616-819-0624
Fax Number	:

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

Provider Enumeration Date	:	03/07/2016
Last Update Date	:	03/07/2016

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Directions to “ AMARIS PORTER ” Practice Location

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