Healthcare Provider Details

I. General information

NPI: 1104276393
Provider Name (Legal Business Name): MISSION SURGICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 PARK SIERRA DR
RIVERSIDE CA
92505-3081
US

IV. Provider business mailing address

200 S MANCHESTER AVE SUITE #315
ORANGE CA
92868-3217
US

V. Phone/Fax

Practice location:
  • Phone: 951-278-8870
  • Fax: 951-278-8913
Mailing address:
  • Phone: 714-456-2986
  • Fax: 714-456-8351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MANUEL PORTO
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.D.
Phone: 714-456-8721