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General NPI Number Information
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NPI Number | 1073990495
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Entity Type | Organization
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Legal Business Name | ORTHOPEDIC AND SPORTS MEDICINE CENTER
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Dates
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Enumeration Date | 05/05/2015
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Last Update Date | 05/05/2015
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Provider Practice Location Address
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Address Line | 1640 NEWPORT BLVD SUITE 230
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City | COSTA MESA
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State | CA
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Zip | 92627-3786
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Country | US
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Telephone | 949-515-5210
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Fax | 855-519-4485
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Provider Business Mailing Address
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Address Line | PO BOX 513228
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City | LOS ANGELES
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State | CA
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Zip | 90051-3228
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Country | US
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Telephone | 714-456-3908
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Fax | 714-456-2338
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Authorized Official
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Title or Position | INTERIM PRESIDENT
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Name | DR. MANUEL PORTO
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Credential | M.D.
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Telephone | 714-456-2986
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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