Basic Information
| Provider Information | |||||||||
| NPI: | 1699800698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L. P. T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2632 | ||||||||
| Address2: | |||||||||
| City: | LAKE ISABELLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932402632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603793412 | ||||||||
| FaxNumber: | 7603791364 | ||||||||
| Practice Location | |||||||||
| Address1: | 2731 NUGGET AVE. | ||||||||
| Address2: | |||||||||
| City: | LAKE ISABELLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932402632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603793412 | ||||||||
| FaxNumber: | 7603791364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT 30178 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.