Provider Demographics
NPI:1588036289
Name:SUSAN SAMUELI CENTER
Entity type:Organization
Organization Name:SUSAN SAMUELI CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & C.E.O.
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 54559
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0559
Mailing Address - Country:US
Mailing Address - Phone:714-456-3724
Mailing Address - Fax:714-456-8101
Practice Address - Street 1:1202 BRISTOL ST
Practice Address - Street 2:SUITE 200
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-8605
Practice Address - Country:US
Practice Address - Phone:714-424-9001
Practice Address - Fax:714-424-9005
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty