Provider Demographics
NPI:1225200439
Name:PORTER, DANIEL D (DC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:D
Last Name:PORTER
Suffix:
Gender:M
Credentials:DC
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 294
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MN
Mailing Address - Zip Code:55043-0294
Mailing Address - Country:US
Mailing Address - Phone:651-436-7724
Mailing Address - Fax:651-436-7724
Practice Address - Street 1:326 SAINT CROIX TRAIL SOUTH
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:MN
Practice Address - Zip Code:55043-0294
Practice Address - Country:US
Practice Address - Phone:651-436-7724
Practice Address - Fax:651-436-7724
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2473111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4C786LAOtherBCBSM
MN3500001391Medicare PIN