Healthcare Provider Details

I. General information

NPI: 1942663653
Provider Name (Legal Business Name): UCI HLTH AT CORONA REG MED CTR- UROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S MAIN ST
CORONA CA
92882-3420
US

IV. Provider business mailing address

PO BOX 51342
LOS ANGELES CA
90051-5642
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-7005
  • Fax: 877-829-7891
Mailing address:
  • Phone: 714-456-6054
  • Fax: 714-456-5342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MANUEL PORTO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-456-2986