Provider Demographics
NPI:1790452746
Name:PORTER, CHEADRICK DEMON
Entity Type:Individual
Prefix:MR
First Name:CHEADRICK
Middle Name:DEMON
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 1:3004 OAK CREST ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-2065
Mailing Address - Country:US
Mailing Address - Phone:409-383-8350
Mailing Address - Fax:
Practice Address - Street 1:3004 OAK CREST ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-2065
Practice Address - Country:US
Practice Address - Phone:409-383-8350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)