Healthcare Provider Details

I. General information

NPI: 1477913630
Provider Name (Legal Business Name): AESTHETIC AND PLASTIC SURGERY INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MANCHESTER AVE SUITE 650
ORANGE CA
92868-3217
US

IV. Provider business mailing address

PO BOX 515072
LOS ANGELES CA
90051-5072
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-3077
  • Fax: 714-456-7718
Mailing address:
  • Phone: 714-456-6655
  • Fax: 714-456-7718

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 & CEO
Credential: MD
Phone: 714-456-2986