Provider Demographics
NPI:1073990495
Name:ORTHOPEDIC AND SPORTS MEDICINE CENTER
Entity Type:Organization
Organization Name:ORTHOPEDIC AND SPORTS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-456-2986
Mailing Address - Street 1:PO BOX 513228
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3228
Mailing Address - Country:US
Mailing Address - Phone:714-456-3908
Mailing Address - Fax:714-456-2338
Practice Address - Street 1:1640 NEWPORT BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3786
Practice Address - Country:US
Practice Address - Phone:949-515-5210
Practice Address - Fax:855-519-4485
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty