1932345360 NPI number — VERNICKA D. PORTER-SALES, DO, PA

Table of content: (NPI 1932345360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932345360 NPI number — VERNICKA D. PORTER-SALES, DO, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VERNICKA D. PORTER-SALES, DO, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932345360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17634 BEAR RIVER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUMBLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77346-1558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-782-2434
Provider Business Mailing Address Fax Number:
218-812-2408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11398 BANDERA RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78250-6840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-543-7334
Provider Business Practice Location Address Fax Number:
210-543-7338
Provider Enumeration Date:
01/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PORTER-SALES
Authorized Official First Name:
VERNICKA
Authorized Official Middle Name:
DASHAWN
Authorized Official Title or Position:
OWNER/PEDIATRICIAN
Authorized Official Telephone Number:
409-899-5439

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  L4650 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 152342501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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