Healthcare Provider Details

I. General information

NPI: 1124496773
Provider Name (Legal Business Name): UC IRVINE HEALTH - CORONA (MEDICINE)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 MAGNOLIA AVE SUITE 205
CORONA CA
92879-3330
US

IV. Provider business mailing address

PO BOX 54509
LOS ANGELES CA
90054-0509
US

V. Phone/Fax

Practice location:
  • Phone: 951-735-4771
  • Fax: 951-735-3835
Mailing address:
  • Phone: 714-456-6585
  • Fax: 714-456-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical 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