Provider Demographics
NPI:1649342346
Name:PORTEOUS, BRIAN J (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:PORTEOUS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 BIRCH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1923
Mailing Address - Country:US
Mailing Address - Phone:949-851-1550
Mailing Address - Fax:949-270-0169
Practice Address - Street 1:4321 BIRCH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1923
Practice Address - Country:US
Practice Address - Phone:949-851-1550
Practice Address - Fax:949-270-0169
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14722111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU30432Medicare UPIN