Provider Demographics
NPI:1730576422
Name:PORTA, JUSTIN PAUL (ATC, CSCS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PAUL
Last Name:PORTA
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N EMERALD DR
Mailing Address - Street 2:APT 77
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6156
Mailing Address - Country:US
Mailing Address - Phone:513-503-3873
Mailing Address - Fax:
Practice Address - Street 1:333 N EMERALD DR
Practice Address - Street 2:APT 77
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6156
Practice Address - Country:US
Practice Address - Phone:513-503-3873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer