Provider Demographics
NPI:1720536550
Name:UC IRVINE HEALTH CDDC HIGH DESERT
Entity Type:Organization
Organization Name:UC IRVINE HEALTH CDDC HIGH DESERT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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 512347
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0347
Mailing Address - Country:US
Mailing Address - Phone:714-456-3856
Mailing Address - Fax:714-456-6216
Practice Address - Street 1:12595 HESPERIA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-5882
Practice Address - Country:US
Practice Address - Phone:760-269-3099
Practice Address - Fax:760-269-3038
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty