Provider Demographics
NPI:1750823720
Name:PORTER, ERIC L
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:L
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 1:700 LONGMONT ST
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-2927
Mailing Address - Country:US
Mailing Address - Phone:307-299-5155
Mailing Address - Fax:
Practice Address - Street 1:700 LONGMONT ST
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-2927
Practice Address - Country:US
Practice Address - Phone:307-299-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor