Provider Demographics
NPI:1952787061
Name:LEPORT
Entity Type:Organization
Organization Name:LEPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-861-4666
Mailing Address - Street 1:18111 BROOKHURST ST
Mailing Address - Street 2:SUITE 5600
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6728
Mailing Address - Country:US
Mailing Address - Phone:714-861-4666
Mailing Address - Fax:714-861-4674
Practice Address - Street 1:18111 BROOKHURST ST
Practice Address - Street 2:SUITE 5600
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-861-4666
Practice Address - Fax:714-861-4674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA963173133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G471930Medicaid
CAW15023Medicare UPIN
CA00G471930Medicaid