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General NPI Number Information
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NPI Number | 1144466384
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Entity Type | Organization
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Legal Business Name | KELLY PORTNOFF, M.D., INC.
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Dates
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Enumeration Date | 12/17/2008
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Last Update Date | 12/17/2008
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Provider Practice Location Address
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Address Line | 25411 CABOT RD SUITE 109
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City | LAGUNA HILLS
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State | CA
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Zip | 92653-5520
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Country | US
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Telephone | 949-364-5119
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Fax | 949-364-1265
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Provider Business Mailing Address
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Address Line | 25411 CABOT RD SUITE 109
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City | LAGUNA HILLS
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State | CA
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Zip | 92653-5520
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Country | US
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Telephone | 949-364-5119
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Fax | 949-364-1265
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. KAREN E OFFORD
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Credential |
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Telephone | 949-364-5119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | A067472
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License Number State | CA
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