Healthcare Provider Details

I. General information

NPI: 1568911303
Provider Name (Legal Business Name): CHOC CHILDREN'S SUBSPECIALTY CLINIC- PULMONARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

IV. Provider business mailing address

PO BOX 54559
LOS ANGELES CA
90054-0559
US

V. Phone/Fax

Practice location:
  • Phone: 888-770-2462
  • Fax: 855-246-2329
Mailing address:
  • Phone: 714-456-3724
  • 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: DR. MANUEL PORTO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-456-2986