Provider Demographics
NPI:1184191280
Name:PORTER, MAURICE SR
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:PORTER
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 PINE ST APT 70
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-2917
Mailing Address - Country:US
Mailing Address - Phone:916-821-1447
Mailing Address - Fax:916-942-9597
Practice Address - Street 1:827 PINE ST APT 70
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-2917
Practice Address - Country:US
Practice Address - Phone:916-821-1447
Practice Address - Fax:916-942-9597
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATCP38035343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)