Provider Demographics
NPI:1841421864
Name:PORRES, EDWIN JR
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:PORRES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 GLENDON AVE APT 6B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-6841
Mailing Address - Country:US
Mailing Address - Phone:310-435-3288
Mailing Address - Fax:
Practice Address - Street 1:12450 VAN NUYS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1391
Practice Address - Country:US
Practice Address - Phone:818-896-1161
Practice Address - Fax:818-896-5069
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA7420Medicaid