Provider Demographics
NPI:1912568841
Name:PORTER, MACK JR (RN)
Entity Type:Individual
Prefix:
First Name:MACK
Middle Name:
Last Name:PORTER
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10802 COLLEGE PL
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-1579
Mailing Address - Country:US
Mailing Address - Phone:562-924-9581
Mailing Address - Fax:
Practice Address - Street 1:10802 COLLEGE PL
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-1579
Practice Address - Country:US
Practice Address - Phone:562-924-9581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA437831163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult