Provider Demographics
NPI:1003967712
Name:PORTEOUS, MICHELLE MISSY (MS, RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MISSY
Last Name:PORTEOUS
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 CONESTOGA CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-8616
Mailing Address - Country:US
Mailing Address - Phone:951-317-7657
Mailing Address - Fax:951-278-8665
Practice Address - Street 1:11801 PIERCE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-4408
Practice Address - Country:US
Practice Address - Phone:951-317-7657
Practice Address - Fax:951-278-8665
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA814382133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00962989OtherRAILROAD MEDICARE
CAZZZ04360ZMedicare PIN