Basic Information
| Provider Information | |||||||||
| NPI: | 1386175594 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHOC SUB-SPECIALTY CLINIC - NEUROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 54778 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900540778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144563851 | ||||||||
| FaxNumber: | 7144566216 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887702462 | ||||||||
| FaxNumber: | 8552462329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2017 | ||||||||
| LastUpdateDate: | 03/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | PORTO | ||||||||
| AuthorizedOfficialFirstName: | MANUEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7144562986 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.