Healthcare Provider Details

I. General information

NPI: 1720536550
Provider Name (Legal Business Name): UC IRVINE HEALTH CDDC HIGH DESERT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

12595 HESPERIA RD SUITE 101
VICTORVILLE CA
92395-5882
US

IV. Provider business mailing address

PO BOX 512347
LOS ANGELES CA
90051-0347
US

V. Phone/Fax

Practice location:
  • Phone: 760-269-3099
  • Fax: 760-269-3038
Mailing address:
  • Phone: 714-456-3856
  • Fax: 714-456-6216

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