Provider Demographics
NPI:1568165629
Name:PORTER, MONTEZ
Entity Type:Individual
Prefix:
First Name:MONTEZ
Middle Name:
Last Name:PORTER
Suffix:
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 1:2823 N 36TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1925
Mailing Address - Country:US
Mailing Address - Phone:414-231-0644
Mailing Address - Fax:
Practice Address - Street 1:2823 N 36TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1925
Practice Address - Country:US
Practice Address - Phone:414-231-0644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider