MEDICARE: MISS VONDRA CARLOTTA PORTER LMT

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	172M00000X	Mechanotherapist	0002333277-0001-9 LA	CA

General Provider Information

NPI Number	:	1962641134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS VONDRA CARLOTTA PORTER LMT

Provider Business Mailing Address
First Line	:	618 N VALLEY ST
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-3147
Country	:	US
Telephone Number	:	818-919-2256
Fax Number	:	818-563-6630

Provider Business Practice Location Address
First Line	:	11318 VENTURA BLVD
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-3137
Country	:	US
Telephone Number	:	818-761-3988
Fax Number	:

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

Provider Enumeration Date	:	02/11/2009
Last Update Date	:	02/11/2009

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