Provider Demographics
NPI:1801568514
Name:PORTER, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HOLT DR
Mailing Address - Street 2:
Mailing Address - City:BIGFORK
Mailing Address - State:MT
Mailing Address - Zip Code:59911-6218
Mailing Address - Country:US
Mailing Address - Phone:406-837-3255
Mailing Address - Fax:
Practice Address - Street 1:850 HOLT DR
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MT
Practice Address - Zip Code:59911-6218
Practice Address - Country:US
Practice Address - Phone:406-837-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2560225100000X
MT21835225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist