Basic Information
| Provider Information | |||||||||
| NPI: | 1134389893 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORTALS HOUSE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PACIFIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 WILSHIRE BLVD STE 500 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900574310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136390251 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 WILSHIRE BLVD STE 500 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900574310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136390251 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2008 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAYTON | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM AIDE | ||||||||
| AuthorizedOfficialTelephone: | 2136390251 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | Y | Managed Care Organizations | Exclusive Provider Organization |
No ID Information.