Individual
MISS PHYLLIS DIANE PORTER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
6650 103RD ST, APT 401, JACKSONVILLE, FL 32210-7143
(904) 559-5434
Mailing address
PO BOX 7064, JACKSONVILLE, FL 32238-0064
(904) 444-3045
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
000809200
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000809200
—
FL
Enumeration date
03/16/2017
Last updated
03/16/2017
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