Provider Demographics
NPI:1114986668
Name:PORTER-FOWLER, PRINCESS CHATEIM
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:CHATEIM
Last Name:PORTER-FOWLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3443
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-3443
Mailing Address - Country:US
Mailing Address - Phone:864-585-4564
Mailing Address - Fax:864-585-5614
Practice Address - Street 1:450 E KENNEDY ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1916
Practice Address - Country:US
Practice Address - Phone:864-585-4564
Practice Address - Fax:864-585-5614
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2762111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2762Medicaid
SCGCH460Medicaid
SCGCH460Medicaid