Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 488 | GA |
NPI | 1215109996 |
---|---|
Provider Name | Alphonso D Porter |
First Address | East Point, GA 30346 |
Second Address | East Point, GA 30346 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2008 |
Last Update Date | 02/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00248289C | (05) | GA |