Provider Demographics
NPI:1740512482
Name:PORTER, CHARLES HENRY IV (DPT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:HENRY
Last Name:PORTER
Suffix:IV
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:1540 EASTCHASE PKWY STE 4A
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-4404
Practice Address - Country:US
Practice Address - Phone:972-979-6577
Practice Address - Fax:817-672-0938
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1187868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist