Healthcare Provider Details

I. General information

NPI: 1912360868
Provider Name (Legal Business Name): UCI HLTH AT CORONA REG MED CTR- OB/GYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 03/16/2017
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 513980
LOS ANGELES CA
90051-3980
US

V. Phone/Fax

Practice location:
  • Phone: 951-736-6375
  • Fax: 951-270-0076
Mailing address:
  • Phone: 714-456-6431
  • Fax: 714-456-7754

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