Basic Information
| Provider Information | |||||||||
| NPI: | 1447613146 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UCI HLTH AT CORONA REG MED CTR- EMERGENCY MED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 513266 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900513266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144563740 | ||||||||
| FaxNumber: | 7144568101 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928823420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144567002 | ||||||||
| FaxNumber: | 8552098413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2016 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PORTO | ||||||||
| AuthorizedOfficialFirstName: | MANUEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7144562986 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | Y | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
No ID Information.