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Individual

MRS. TINA MARIE PORTA

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F
Credential
COTAL

Contact information

Practice address
15618 ETON CT., MACOMB, MI 48044
(586) 791-9204
Mailing address
15618 ETON CT, MACOMB, MI 48044-1127
(586) 419-0636

Taxonomy

Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
L1568305
MI

Other

Enumeration date
04/15/2010
Last updated
04/15/2010
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