Provider Demographics
NPI:1861596561
Name:PORTER CHIROPRACTIC CLINIC PA
Entity type:Organization
Organization Name:PORTER CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:L
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:620-345-3000
Mailing Address - Street 1:121 S. CHRISTIAN AVE.
Mailing Address - Street 2:P.O. BOX 743
Mailing Address - City:MOUNDRIDGE
Mailing Address - State:KS
Mailing Address - Zip Code:67107-0743
Mailing Address - Country:US
Mailing Address - Phone:620-345-3000
Mailing Address - Fax:620-345-3042
Practice Address - Street 1:121 S. CHRISTIAN AVE.
Practice Address - Street 2:
Practice Address - City:MOUDRIDGE
Practice Address - State:KS
Practice Address - Zip Code:67107-0743
Practice Address - Country:US
Practice Address - Phone:620-345-3000
Practice Address - Fax:620-345-3042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-04311111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS60494POMedicare ID - Type Unspecified
KSU605083Medicare UPIN