Provider Demographics
NPI:1124586516
Name:PORCH, LATARA U
Entity Type:Individual
Prefix:
First Name:LATARA
Middle Name:U
Last Name:PORCH
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 1:3309 PARKMILL DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-6470
Mailing Address - Country:US
Mailing Address - Phone:813-409-4146
Mailing Address - Fax:
Practice Address - Street 1:3309 PARKMILL DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-6470
Practice Address - Country:US
Practice Address - Phone:813-409-4146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1744P3200XMedicaid