Basic Information
| Provider Information | |||||||||
| NPI: | 1225224389 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVIERA MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | URGENT CARE AT NEWPORT CENTER, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 SAN MIGUEL DR | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926607853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497608300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 360 SAN MIGUEL DR | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926607853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497608300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOONAN | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9497608300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | A78014 | 01 | CA | CA MEDICAL BOARD | OTHER |