Provider Demographics
NPI:1962641134
Name:PORTER, VONDRA CARLOTTA (LMT)
Entity Type:Individual
Prefix:MISS
First Name:VONDRA
Middle Name:CARLOTTA
Last Name:PORTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 N VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-3147
Mailing Address - Country:US
Mailing Address - Phone:818-919-2256
Mailing Address - Fax:818-563-6630
Practice Address - Street 1:11318 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-3137
Practice Address - Country:US
Practice Address - Phone:818-761-3988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0002333277-0001-9 LA172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist