Provider Demographics
NPI:1790522746
Name:O'BRAINT, PORTUGAL (MLS(ASCP))
Entity type:Individual
Prefix:
First Name:PORTUGAL
Middle Name:
Last Name:O'BRAINT
Suffix:
Gender:F
Credentials:MLS(ASCP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:MERIGOLD
Mailing Address - State:MS
Mailing Address - Zip Code:38759-0070
Mailing Address - Country:US
Mailing Address - Phone:662-410-9196
Mailing Address - Fax:
Practice Address - Street 1:83 MANNING ROAD
Practice Address - Street 2:
Practice Address - City:MERIGOLD
Practice Address - State:MS
Practice Address - Zip Code:38759
Practice Address - Country:US
Practice Address - Phone:662-410-9196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL266584156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist