=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922484450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UC IRVINE HEALTH MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2015
-----------------------------------------------------
Last Update Date | 08/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1451 IRVINE BLVD
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92780-3804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-515-5210
-----------------------------------------------------
Fax | 855-519-4485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 513228
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90051-3228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-456-3908
-----------------------------------------------------
Fax | 714-456-2338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND CEO
-----------------------------------------------------
Name | DR. MANUEL PORTO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-456-2986
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------