Provider Demographics
NPI:1023383130
Name:PORTERS, MICHAEL VINCENT (ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VINCENT
Last Name:PORTERS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 STORMY CT
Mailing Address - Street 2:APT 201
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-5197
Mailing Address - Country:US
Mailing Address - Phone:847-975-8575
Mailing Address - Fax:
Practice Address - Street 1:500 W ELK GROVE BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-4272
Practice Address - Country:US
Practice Address - Phone:847-718-4507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer