Healthcare Provider Details

I. General information

NPI: 1396687026
Provider Name (Legal Business Name): PORCUPINE CROSSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12681 HASTER ST
GARDEN GROVE CA
92840-6040
US

IV. Provider business mailing address

3401 N THANKSGIVING WAY STE 190
LEHI UT
84048-4157
US

V. Phone/Fax

Practice location:
  • Phone: 385-454-5027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRIAN NEWBERRY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 385-454-5027