Healthcare Provider Details

I. General information

NPI: 1871971002
Provider Name (Legal Business Name): UC IRVINE MEDICAL CENTER- ALS & NEUROMUSCULAR CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MANCHESTER AVE SUITE 110
ORANGE CA
92868-3217
US

IV. Provider business mailing address

PO BOX 54778
LOS ANGELES CA
90054-0778
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-2332
  • Fax: 714-456-5997
Mailing address:
  • Phone: 714-456-3851
  • Fax: 714-456-6216

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