MEDICARE: MRS. MICHELLE MISSY PORTEOUS MS, RD, CDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	814382	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00962989	OTHER	CA	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1003967712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE MISSY PORTEOUS MS, RD, CDE

Provider Business Mailing Address
First Line	:	1275 CONESTOGA CIR
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92881-8616
Country	:	US
Telephone Number	:	951-317-7657
Fax Number	:	951-278-8665

Provider Business Practice Location Address
First Line	:	11801 PIERCE ST
Second Line	:	SUITE 200
City	:	RIVERSIDE
State	:	CA
Zip	:	92505-4408
Country	:	US
Telephone Number	:	951-317-7657
Fax Number	:	951-278-8665

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	09/03/2013

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