Healthcare Provider Details

I. General information

NPI: 1184002198
Provider Name (Legal Business Name): UC IRVINE MEDICAL CENTER- GERIATRICS, PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S SENIOR CENTER, PAV IV
ORANGE CA
92868-3201
US

IV. Provider business mailing address

PO BOX 54509
LOS ANGELES CA
90054-0509
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-7007
  • Fax: 714-456-2890
Mailing address:
  • Phone: 714-456-3856
  • Fax: 714-456-8101

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: MANUEL PORTO
Title or Position: INTERIM PRESIDENT
Credential: MD
Phone: 714-456-2986