Provider Demographics
NPI:1063668374
Name:PORTER CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:PORTER CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DM, DC
Authorized Official - Phone:330-452-8811
Mailing Address - Street 1:1412 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44703-3103
Mailing Address - Country:US
Mailing Address - Phone:330-452-8811
Mailing Address - Fax:330-452-8871
Practice Address - Street 1:1412 CLEVELAND AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44703-3103
Practice Address - Country:US
Practice Address - Phone:330-452-8811
Practice Address - Fax:330-452-8871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH009880-8Medicaid
OH009880-8Medicaid