Basic Information
| Provider Information | |||||||||
| NPI: | 1386794485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6508 GUNN HIGHWAY | ||||||||
| Address2: | INDEPENDENT LIVING INC | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336254022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139636923 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Practice Location | |||||||||
| Address1: | 6508 GUNN HIGHWAY | ||||||||
| Address2: | INDEPENDENT LIVING INC | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336254022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139636923 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 0000614 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 11948301 | 01 | FL | CITRUS | OTHER | 355520 | 01 | FL | WELLCARE | OTHER | Y9812 | 01 | FL | BCBS | OTHER |