Provider Demographics
NPI:1750072450
Name:PORTER PELVIC PHYSICAL THERAPY
Entity type:Organization
Organization Name:PORTER PELVIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:G
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:386-227-6077
Mailing Address - Street 1:106 OLD CARRIAGE RD
Mailing Address - Street 2:
Mailing Address - City:PONCE INLET
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 OLD CARRIAGE RD
Practice Address - Street 2:
Practice Address - City:PONCE INLET
Practice Address - State:FL
Practice Address - Zip Code:32127-6910
Practice Address - Country:US
Practice Address - Phone:386-227-6077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy