Provider Demographics
NPI:1346351905
Name:PORTER, CLYDE WILLIAM (DC)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:WILLIAM
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 20788
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89515-0788
Mailing Address - Country:US
Mailing Address - Phone:775-331-0177
Mailing Address - Fax:775-331-8391
Practice Address - Street 1:1005 TERMINAL WAY STE 270
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-2181
Practice Address - Country:US
Practice Address - Phone:775-331-0177
Practice Address - Fax:775-331-8391
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB115111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV88-0178222OtherNEVADA TAX ID